June 2010

Feasibility Study of Stakeholder Commitment

Global Measles Eradication

www.coxsi.com

Executive Summary 2

1. Background, Objective and Methodology 4

1. 1 Background 41. 2 Objective 41. 3 Methodology 5

2. Findings 6

2. 1 Status 62. 2 Stakeholders 72. 3 Perception of Eradication 92. 4 Measles vs. Polio 122. 5 Perception of Measles Initiative 132. 6 Perception of Political Will 162. 7 Perception of Financing Ability 152. 8 Societal Considerations 172. 9 Special Concerns 17

3. Recommendations and Conclusions 19

Appendix

Appendix 1: List of interviewees and e-survey respondentsAppendix 2: E-survey questionnaireAppendix 3: E-survey findingsAppendix 4: Summary profiles of potential partner organizations

World Health Organization would like to extend its sincere thanks and appreciation to the many stakeholders who willingly gave their time to participate in the e-survey, consultations and phone interviews conducted by Coxswain Social Investment plus (CSI+) over the course of the past few months.

Table of Contents

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Remarkable progress has been made in the fight against measles in the past 10 years. At the May 2008 Meeting of the Executive Board (EB) of the World Health Assembly (WHA) a request was made to WHO to examine the feasibility of global measles elimination, and at the WHA in May 2010, Member States endorsed milestone targets for 2015 that could potentially lead to eradication. All countries have in addition agreed to regional elimination goals.

It is recognized, however, that many barriers need to be overcome. These include:

weak immunization and disease surveillance systems;difficulties in vaccinating hard-to-reach populations (including in areas affected by conflict or natural disaster); competing public health priorities; sustaining high routine vaccination coverage; addressing the USD 298 million funding gap;addressing an increasing number of measles outbreaks particularly in cross-border areas; and

1lack of political and financial commitment.

WHO has conducted some studies on the feasibility of measles eradication and determined that measles can be eradicated on biological (i.e. humans are the only host) and technical (i.e. effective vaccine and strategy) grounds. Additionally, the feasibility assessments also include programmatic and economic elements and attention to the impacts of an eradication programme on health systems.

This assessment of stakeholder political will and financial capacity to support a future measles eradication goal is one of seven assessments responding to the EB request.

The aim of this rapid assessment is to assess the political and financial capacity to support another eradication initiative when it appears likely that the existing ones (polio and guinea worm) will continue for at least several additional years. In particular, this assessment focuses on:

1. identification of key stakeholders of global measles eradication

2. analysis of potential sources of funds for measles eradication and key donor perspectives and interests in funding a global measles eradication initiative in light of other competing funding priorities and

3. potential impact of the current economic crisis on resource mobilization for measles eradication.

Data for this study was collected from interviews, consultations and an online survey. The data was categorized and analysed using an interpretive-based content analysis method.

The findings reveal a rather broad range of views with respect to the introduction of a measles eradication goal. Views seem to be influenced by personal experiences with other disease eradication efforts, notably the Global

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1Questions and Answers on Global Eradication on Measles, 63rd World Health Assembly, 14 May 2010

Executive Summary

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Polio Eradication Initiative. The findings are grouped into three main sections:

Stakeholders. The report seeks to identify internal and external stakeholders. Whereas internal stakeholders were relatively easy to identify and largely are represented by the Measles Initiative, external stakeholders proved far more difficult to identify apart from the grouping “civil society organizations”. In going forward, it was recommended to further explore and engage strategic external stakeholders.

Perceptions. The study uncovers perceptions as they relate to eradication, the Measles Initiative, political will and financing ability. The study respondents fell into three categories 1) eradication now 2) eradication later and 3) eradication never, with an approximately equal distribution among the three categories. The perception of the Measles Initiative was very positive and it was considered to represent the pillar of a future initiative. However, the perception of political will – notably in the two large UN organizations (WHO and UNICEF) – seemed to be very low and has to be addressed in going forward. Finally, there seems to be little donor agency financing ability to undertake another eradication initiative.

Special concerns. Many perceptions articulated as concerns were raised covering a range of issues. The ones found pertinent to this study are included in a special concerns section. These include (i) the perceived low public health threat represented by the disease (ii) the incompatibility of a vertical disease specific initiative with international public health strategies and focus (iii) the financial crisis and reduction in development agency aid for specific programmes (iv) the significance of engaging the Government of India (v) the complexity of measles surveillance and finally, but very importantly (vi) the lack of skilled advocacy, communication and fundraising expertise in the Measles Initiative.

This study concludes that the time may not be ripe for the introduction of a measles eradication goal before one of two conditions has been met, namely either that 1) global polio eradication has been successfully concluded or 2) long-term financing is identified to launch, sustain and conclude a measles eradication initiative.

Finally, CSI+ offers a set of opportunities and actions for the measles initiative to consider in going forward. The suggestions include (i) seizing the opportunity represented by MDG 4 (ii) strengthening the Measles Initiative with strategic partner additions and supplementary advocacy, communication and fundraising skills (iii) devising strategies and executing plans with an integration focus as opposed to vertical disease emphasis and (iv) capitalizing on the wealth of experience of the Global Polio Eradication Initiative, notably by securing funding for a future eradication goal up front.

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1.1 Background

1.2 Objective

Remarkable progress has been made in the fight against measles in the past decade. The Americas have interrupted transmission and are only experiencing outbreaks linked to importations. The other WHO regions (Africa, Europe, Eastern Mediterranean and Western Pacific) have established measles elimination goals and achieved or exceeded the target of 90% measles mortality reduction. Only the South East Asian region has yet to adopt a regional elimination target, but is expected to do so shortly.

Recognizing the tremendous progress and commitment made by countries throughout the world, the Executive Board (EB) of the World Health Assembly (WHA) made a request to WHO to examine the feasibility of global measles elimination and report back to the EB. Subsequently WHO’s Department of Immunization, Vaccines and Biologicals commissioned a number of assessments including biological feasibility; the economic aspects and the cost effectiveness of eradication; the programmatic and operational feasibility; the vaccine market and the impact on vaccine demand and supply; the impact of eradication activities on health systems; post-eradication transmission risks and finally an analysis of the stakeholder political will and financial feasibility from a global perspective.

The International Task Force on Disease Eradication reviewed measles as a candidate for eradication at its meeting in June 2009 and concluded that “measles eradication is biologically feasible using tools that are currently available, as already demonstrated in the Americas, although implementation challenges remain in each of the remaining five regions”. For example, as of November 2002, the Americas Region has interrupted measles virus transmission.

At the World Health Assembly in May 2010, Member States endorsed important global measles targets for 2015 that are proposed as milestones towards global eradication of measles. These include achievement of the Global Immunization Vision and Strategy’s goal to increase vaccination coverage as well as targets for reduction of incidence and mortality:

exceed 90% coverage with the first dose of measles-containing vaccine nationally and exceed 80% vaccination coverage in every district or equivalent administrative unit;reduce annual measles incidence to less than five cases per million and maintain that level;

2reduce measles mortality by 95% or more in comparison with 2000 estimates.

The purpose of this stakeholder analysis is three-fold:to identify and gain a clear understanding of the main stakeholders to understand their perceptions, attitudes, interests and support for a measles eradication initiative to draw some preliminary conclusions that may inform a future partnership and funding strategy for measles.

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1. Background, Objectives and Methodology

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225 March 2010 WHA Provisional Agenda Item 11.15, Report by the Secretariat: Global Eradication of Measles

1.3 Methodology

The stakeholder analysis was carried out using a combination of data collection methodologies including literature and desk review, on-line survey, e-mail questionnaires and phone consultations and conference calls.

For the phone and conference calls, a staggered approach was applied in which interviewees were divided into three tiers representing internal and external stakeholders. The first tier of individuals involved WHO representatives including HQ and Regional staff working directly on or responsible for measles control. The objective of these consultations was to understand progress and challenges as they pertain to the global and regional levels and to solicit suggestions and ideas.

The second tier focused on Measles Initiative representatives and had – apart from the objective of soliciting comments and ideas – the goal of identifying additional stakeholders and individuals who could be included both in the consultation process and ideally engaged at a later stage.

The third tier of the consultation process included organizations and individuals currently external to the Measles Initiative. Attempts were made to interview a representative sub-set of agencies that had responded to the survey and by doing so indicated an interest in the measles initiative. A complete list of interviewees is included in Appendix 1.

Initial contacts were made by emails containing a brief on the assessment and the purpose of the interviews. 46 individuals – representing all WHO regions (6), major development agencies with a history of supporting immunization efforts (9), foundations (2), NGOs (8) and other international development organizations (2) were asked to make themselves available for a phone consultation with the Project Manager. They were also encouraged to complete an online survey created at Survey Monkey. 28 individuals completed the online survey, and 20 individuals (43%) accepted the invitation to be interviewed. It should be noted that some represented the same organization.

Interviews were designed to be unstructured and open ended in order to change and adapt to each individual's particular perception, level of knowledge and expertise. They were intended to generate insights about levels of commitment, personal and organizational perceptions about eradication and receptiveness to financially supporting an eradication initiative. The format of the interviews permitted a high degree of flexibility in data and information collection and allowed issues, ideas and challenges to surface. Interviews were conducted over a 3-week consultation period and ranged in duration from 15-90 minutes.

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This section presents and analyses the data and information collected. It is introduced by a short summary detailing the current status of global measles efforts followed by an analysis of data and key findings. A copy of the e-survey questionnaire is included in Appendix 2. The in-depth analysis of e-survey data is included in Appendix 3. During the consultations, many different views, comments and suggestions were captured, some of which are included as quotes. As some of the individuals interviewed requested and were assured confidentially and anonymity, such illustrative quotes are included without naming the source.

Status of Control Efforts. Progress on measles control over the last decade has been substantial: global mortality due to measles has been reduced by 78%, from an estimated 733 000 deaths in 2000 to an estimated 164 000 deaths in 2008. All WHO regions have already achieved this goal, with the exception of the South-East Asia Region, but within that Region it has been achieved by all countries except India. In 2008, global routine coverage with the first dose of measles-containing vaccine reached 83%, an increase from 72% in 2000. In 2008, more than 110 million children received measles-containing vaccine through supplementary immunization activities in the 47 priority countries identified

3 as having a high measles mortality burden in 2000. However, recent inability to sustain control efforts has resulted in rapid resurgence of measles and a considerable number of unnecessary deaths associated with outbreaks in Angola, Benin, Botswana, Bulgaria, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Cote d’Ivoire, Democratic Republic of the Congo, Ethiopia, Guinea - Conakry, Indonesia, Kenya, Lesotho, Liberia, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, The Philippines, Senegal, Sierra Leone, Somalia, South Africa, Swaziland, Tanzania, Thailand, Togo, United Kingdom, Vietnam, Zambia, and Zimbabwe.

Leadership. Although measles efforts so far largely have been implemented at country level, significant global leadership is provided by the Measles Initiative. Established in 2001, the Partnership includes CDC, UNF, ARC, WHO and UNICEF as core partner organizations and is supplemented as and when needed by a number of NGOs, public and private organizations.

Political Will. The World Health Assembly in May 2010 marked an important milestone on the path to eradication in that Member States endorsed a series of interim targets set for 2015 to:

exceed 90% first-dose vaccination coverage nationally and exceed 80% vaccination coverage in every district or equivalent administrative unit;reduce annual measles incidence to <5 per million and maintain that level;reduce measles mortality by 95% or more in comparison with 2000 levels.

Member States acknowledged at the same occasion that although the targets are achievable, significant barriers exist for reaching them and sustaining existing efforts. Key challenges are associated with (a) weak immunization and disease surveillance systems (b) difficulties in reaching hard-to-reach-populations (c) lack of political and financial commitment (d) competing public health priorities (e) sustaining high routine vaccination coverage (f) addressing the USD 298 million funding gap (g) addressing an increasing number of measles outbreaks particularly in cross-border areas.

2. 1 Status

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2. Findings

Measles is a success - the 92% reduction in Africa is unheard of in

public health history.

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325 March 2010 WHA Provisional Agenda Item 11.15, Report by the Secretariat: Global Eradication of Measles

Financing. The Measles Initiative has in the past significantly benefited from emergency and humanitarian aid funding. Financial contributors have largely been the core members of the Measle Initiative (CDC, American Red Cross United Nations Foundation, UNICEF WHO supplemented by financial contributions from Merck (surveillance), Vodacom Foundation and the Church of Jesus Christ of Latter Day Saints (operational costs). Additionally, in 2010 the Bill and Melinda Gates Foundation provided funding to the Task Force for Global Health for a collaborative project with the Carter Center – Accelerated Measles Mortality Reduction Improving Routine Immunizations in Africa.

The estimated funding gap between now and 2015 to achieve the measles goals is nearly US$ 300 million.

2. 2 Stakeholders

Internal stakeholders already included in the Measles Initiative were relatively easy to identify. They include the Measles Initiative core partners such as CDC, UNF, ARC, WHO and UNICEF, as well as partners that have committed in the past, including but not limited to the Latter Day Saints, Merck Foundation, Bill and Melinda Gates Foundation, CIDA and GAVI. The interviewees for this report almost unilaterally agreed that the members of the Measles Initiative represented the majority of skills, expertise, commitment, leadership, human resources and financial commitment needed for maintaining existing efforts and possibly moving towards eradication.

Interviewees were invited to provide suggestions during consultations and in the e-survey for external stakeholders and asked to help identify the most important stakeholder groups for a successful initiative (see Figure 1).

Sadly, measles is a victim of its own success.

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Figure 1: Perceived importance of different groups of stakeholders

Percentage

72.2%

83.3%

39.9%

50.0%

55.6%

61.1%

38.9%Engagement of media

Creation of community and grassroot demand

Involvement of high profile opinion leaders

Achieving other eradication goals notably polio eradication

Financial/political commitments from other donors

Financial/political commitments from host country government

Financial/political commitments from donor government

Table 1: Proposed stakeholders and roles

Organization

Proposed Role

Advocacy CommunicationSocial

Mobilization

Funding/Fundraising

Lions Clubs International

Kiwanis International

IFRC AMP Initiative

Helen Keller International

GAVI Alliance

Sabin Vaccine Institute

King Faisal Foundation

Merck & Co., Inc.

GlaxoSmithKline Biologicals

Serum Institute of India

Sanofi Pasteur

Appendix 5 includes a brief summary of each organization or partner opportunity that could be further explored.

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There was consensus (83.3% of the respondents) that national/host government commitment – ideally in the form of co-financing – would be required to sustain existing control efforts and potentially achieve an eradication target. Donor agencies (72.2% of respondents) and groups working on demand creation (61.1% of the respondents) were also perceived to be important, as was the involvement of high profile leaders (55.6% of the respondents).

However, it was equally unanimously agreed that new partners had to be engaged to acquire skills, expertise and/or support with:

1. advocacy2. communication3. social mobilization/demand creation4. fundraising or financing

The following table (see Table 1) represents the suggestions made for additional stakeholders and some possible roles proposed.

2. 3 Perception of Eradication

“Eradication now”

“Eradication later”

“Eradication never”

During the individual consultations and interviews it became clear that the word ‘eradication’ itself triggered quite emotional reactions that in turn influenced responses and views. The Global Polio Eradication Initiative clearly was used as reference – in both a positive and negative way – and the general consensus was that the continuous set-backs of the Polio Eradication Initiative already had or potentially could discourage donors and partners.

A few schools of thoughts on eradication appeared to have developed: 1) eradication now 2) eradication later 3) eradication never.

This group considered eradication the only logical next step as all countries already have made a political commitment to the 2015 goals. They argued that lack of progress on the Polio Eradication Initiative should not negatively impact the measles eradication trajectory. Some individuals indicated that should an eradication goal be introduced, they would at a minimum maintain or be likely to increase the current level of funding and personnel effort. This group strongly argued against an incremental increase of the target from e.g. 90% to 95% or even 98%. They suggested that no donor, partner or national government would have an incentive to make an effort to reach only an incrementally increased target. Only an eradication goal would entice national government and donors.

The sub-set of stakeholders arguing for eradication later seem to endorse the recommendation of WHO’s Strategic Advisory Group of Experts on Immunization, which warned against establishing a measles eradication goal while polio eradication is not yet complete. The crux of this argument is that full attention must be given to polio and therefore two parallel eradication initiatives cannot co-exist.

Some of the individuals interviewed argued that eradication should never be introduced, notably because of the many challenges faced by the Polio Eradication Initiative. Some stated that eradication initiatives have had a negative impact on heath system strengthening and routine immunization, as demonstrated by the Polio Eradication Initiative, and could not reasonably be justified. One argued that global eradication goals are inflicted on national governments that have other priorities and plans, and that an eradication initiative by default would fail. Another opinion was that eradication is not in the global public health interest (see quotation). Another important argument was that the

It is unacceptable to tolerate child deaths that can easily be prevented.

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...countries are manipulated by epidemiological cowboys.. (that) have little appreciation for development and nurturing countries to meet their self

identified needs...

Eradication is inevitable but everyone has to be realistic on how much can

be kept on the plate at one time.

investment case with necessary scientific evidence on feasibility and a comprehensive cost benefit analysis had not been presented. It was argued that the cost per life saved or case averted would become high and conflict with public health principles of efficiency and effectiveness. One compromise solution was to incrementally raise the measles mortality goal to e. g. 95% or 98% with the argument that the end result would be the same as a formal eradication goal – namely no measles due to the high herd immunity.

In the e-survey, 126 individuals representing government donor agencies, international agencies, foundations and NGOs were asked to indicate if they personally would support an eradication goal and if they believed their organization would do so.

The results (see Figure 2) suggest that individuals informed of or involved with the measles effort appear to be more supportive personally than their organizations.

The findings also suggest that there are committed professionals in partner organizations that may be able to play a greater advocacy role internally.

Figure 2: Personal and organizational commitment

Perc

enta

ge

Highly likely Likely Not likely

Organizational

Personal

44%

54.2%

24%

12.5%

32% 33.3%

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Figure 3: Some correlation between knowledge levels and perceived organizational support

It appears that the more knowledgeable the respondent indicated to be about measles eradication, the higher the likelihood of a perceived organizational commitment (see Figure 3).

The majority (28%) of individuals who indicated that they were not likely to support a measles eradication initiative represented international donor agencies or international development institutions (see Figure 4). Although not conclusive there seems to be some evidence that donor agencies and some development agencies have little or insufficient knowledge about measles eradication and the implications of an eradication goal (e.g. the eradication strategy and the impact of measles eradication activities in health systems), and that this lack of information translates into a negative level of support.

Perc

enta

ge

Highly likely Likely Not likely

1

2

4% 4% 4%

The more knowledgeable about Measles, the higher likelihood of Organizational support to an initiative

(1=highest, 5=lowest level of knowledge)

Significant personal resistance for a goal at Donor Agency level

3

4

5

15%

30%

11%7%

7%11%

7%

Figure 4: Donor agency resistance

Perc

enta

ge

Highly likely Likely Not likely

Donor government/Government agency

International development institution

18%9%

5%

NGO

Foundation

18%

18%

5%5%

23%

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2.4 Measles vs. Polio

As mentioned above, the Global Polio Eradication Initiative frequently surfaced in individual stakeholder consultations for reference as a good or not so good example of best practice. The table to the right (see Table 2) summarises the major differences as perceived by the majority of individuals interviewed.

Polio Measles

Top down (WHO/HQ led)

No co-financing on the part of the country

More costly

Simple administration

Activities required 4-6 times per year in endemic countries

Uncertainty about strategy for going the last mile

Little emphasis on integration

Bottom up (national government led)

Country co-financing commitment

Less costly

Requires trained personnel and injectionsl

Activities required every 3-4 yrs

Scalable model in place for replication

Striving for integration and delivery of other interventions

Some individuals argued that the significant success the Global Polio Eradication Initiative had enjoyed in securing financial support and partner commitment was due to the vertical and very focused nature of the initiative and the fact that it was coordinated, executed and managed centrally at WHO in Geneva. Some of these individuals suggested replication of the PEI model for measles.

However, some individuals (mainly representing international development agencies) argued that the time had passed for vertical global health initiatives and that an eradication goal does not have to be a stand alone program but rather integrated with other interventions including but not limited to bednet distribution, nutritional supplement provision and child health day service delivery.

A few individuals contended that the two programmes – due to their similar nature – could mutually benefit from better coordination and planning and possibly from joint external relations and fundraising. All seemed to agree that the Global Polio Eradication Initiative had been particularly successful because of a very committed project team and its skilled human resources who effectively manage donors and partners, undertake strategic advocacy and communication efforts and provide reporting and quality data with the frequency and detail needed to strategically orient efforts. This expertise and experience could be replicated and adapted to suit a global measles eradication initiative.

Representatives of the Global Polio Eradication Initiative advised that a future measles eradication initiative be launched as a new effort and tap into different resources. Polio is encountering financing challenges too and is considered by many an ‘old initiative’. It was feared that the association would not benefit measles efforts.

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Table 2: Polio vs. Measles

2. 5 Perception of Measles Initiative

Leadership was raised in several interviews as an essential success factor for an eradication initiative. During the consultation process individuals were asked if they have working experience with Measles Initiative members and if so, to elaborate on what they believe works well and what they believe needs improvement to sustain current control efforts and potentially lead to an eradication initiative.

The table below (see Table 3) highlights what stakeholders find works well and what could be improved.

The Partnership is getting a lot done with little resources.

Table 3: Measles Initiative successes and suggested improvements

Works Well Could be Improved

Weekly calls

Consensus driven decision making

Country ownership – unique that countries are asked to pick up the tab

Representation and inclusion

Enthusiasm, leadership and engagement of core partners

Everyone has a voice and everyone recognizes it

Room to navigate, no major turf battles

Advocacy and resource mobilization expertise and efforts

Data collection, availability and dissemination includingfinancing needs (borrow from Polio)

Strengthen epidemiology and strategic planning

Advocacy efforts

Consists of 'friends' that have worked together before (notably at CDC). Great trust and prior working relationships

Commitment to make it happen

In general there was consensus that the Measles Initiative as it is known today has to continue to play a significant role. However, some indicated that the varying degrees of commitment of Measles Initiative partners was beginning to show and that ‘fatigue’ in some of the organizations begged the question whether existing partners had the impetus and stamina to continue or if another partnership constellation should be considered.

It was noted by some that a measles eradication initiative had to be far more inclusive than is currently the case. Many highlighted the need for external assistance to conduct advocacy, communication and social mobilization efforts and financing partners to help underwrite campaigns and initiatives.

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2.6 Perception of Political Will

Measles eradication has been on the minds of many for decades. In fact, measles eradication was originally discussed as a possibility at the same time polio was adopted as an eradication goal in 1988. Since then, measles control targets have been revised and increased in response to Member State commitments and political will.

In 2003, WHA passed a resolution to reduce global measles mortality by 50% from 1999 levels by 2005, a goal that has been achieved. At the WHA in 2005, Member States welcomed the Global Immunization Vision and Strategies document (GIVS) endorsing a goal to reduce global measles mortality by 90% in 2010 compared with the 2000 level

At the recently concluded WHA, Member States endorsed the interim targets set for 2015 as milestones towards the eventual global eradication of measles. They include:

exceed 90% coverage with the first dose of measles-containing vaccine nationally and exceed 80% vaccination coverage in every district or equivalent administrative unit;reduce annual measles incidence to less than five cases per million and maintain that level;

5reduce measles mortality by 95% or more in comparison with 2000 estimates.

Member States recognized at the same occasion that meeting the measles 2015 targets is critical for achieving the Millennium Development Goal 4 to reduce child mortality.

Political will is required at multiple levels, namely:1. In core partner organizations;2. In the country needing the proposed intervention; 3. In the international donor community requested to finance or co-finance efforts.

Interestingly, several individuals interviewed expressed concerns about a perceived leadership vacuum at the highest level of several organizations – notably in WHO and UNICEF. Figure 5 seeks to capture the perception of leadership commitment in each of the lead agencies.

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4Wolfson LJ, Strebel PM, gacie-Dobo M, Hoekstra EJ, McFarland JW, Hersh BS (2007): Has the2005 measles mortality reduction goal been achieved? A

natural history modeling study. Lancet 369, 191-200525 March 2010 WHA Provisional Agenda Item 11. 15, Report by the Secretariat: Global Eradication of Measles

Figure 5: Perceived Organizational Commitment and Leadership

High

High

Low

Low

ARC

UNICEFWHO

CDCUNF

Leadership

Leadership

Organizational Committment

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2.7 Perception of Financing Ability

Thus far it has mainly been CDC, UNF and ARC that have financed campaigns and efforts, with CDC as the lead agency and financial contributor. UNF manages the funds of the Measles Initiative through an agreement with the UN and disburses and accounts for these funds through the UN financial system. Financing generated for measles by ARC has been generated in association with emergencies and outbreaks such as the tsunami and earthquakes.

With the ambitious interim goal endorsed at the WHA in May 2010 and envisaging a future measles eradication goal, new financing partners are needed to cover the funding shortfall to sustain control efforts and guarantee execution of critical functions and activities.

Individuals contributing to this report were surprisingly unconcerned with the cost of an eradication initiative. It was assumed that ‘the others’ could cover any costs or funding would be mobilized elsewhere. Individuals interviewed mentioned that bilateral donor agencies need to be involved, which represents the traditional view that bilateral donor agencies will and can continue to identify and commit to the financing of novel initiatives.

In addition to approaching the US Government for funding – which is already committing resources via CDC – individuals consulted suggested approaching the Governments of Canada, Italy, Norway, Netherlands and UK since they have traditionally supported immunization. However – as indicated above – significant funding challenges arise from the financial crisis combined with a new international aid architecture (which places emphasis on support to basket arrangements) and importance given to health system strengthening. The Government of the Netherlands, for example, recently re-negotiated its arrangement with WHO for provision of un-earmarked funding to be spent on priorities as set by WHO leadership. Although the arrangement objectively is very beneficial to WHO as an organization, it is detrimental to a possible measles eradication initiative.

Measles financing is plagued by an additional challenge: there is no demand generated by mothers to vaccinate their children as they are no longer suffering from the disease in the same numbers as before. In fact many mothers no longer recognize measles as a threat to their children due to the tremendous success in controlling it. Furthermore, there is no supply – i.e. voluntary commitment from donors recognizing it as a priority.

Country level financing has to be further explored. This requires strong engagement and advocacy at the country level to e.g. convince national governments and donor organizations to contribute to basket funds that set aside money for measles efforts.

Reality is that measles in the industrialized world is not a challenge. Today’s generation of donors do not consider it as a public health threat along the many other competing health challenges, in fact many of

them may have even had the disease without dying from it.

Countries need to be doing more than they are currently doing.

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The table below (see Table 4) summarizes the main tendencies and trends of funding for the major government agencies.

Table 4: Government funding trends

Health focus Comments

Australia

Canada

Italy

USD 11m in food aid and assistance for displaced persons in Somalia, DRC, Kenya

Possible USD 947m for maternal & child health

Plan to spend USD 163.8m in Africa for 2010-2011 financial year

Aid budget frozen in 2010, but development initiatives for maternal & child health not expected to be affected

Italian Cooperation has used all of its 2010 allocation, and most resources for 2011 have already been allocated for multi-year projects

USD 149m (2002-2006)

USD 120mMaternal health

Maternal & child health, health care worker training, primary health care service strengthening

Health sector reform, strengthening of child and maternal health services

Japan

Netherlands*

Norway

UK

Infectious disease, maternal & child health, public health system strengthening, HR development

Health sector reform

UN earmarkingGAVI alliance core funding

USD 246.8m 2010 Global Fund contribution and renewed verbal commitment to fund elimination efforts

New government (the fourth in just eight years) will be elected shortly. Currently a 'leadership vacuum'. Committed to central – un earmarked – funding for e. g. WHO

Maternal & child and women's health, health system strengthening

Committed to central – un earmarked – funding for e. g. WHO

USD 191m (2001-2009)

None

USD 441m (2001-2009)

Health sector reform Agreement under new coalition government: plans to enshrine into law UK commitment to spend 0.7 of GNI on aid. New government pledges to re-consider international development aid

USD 122m (2000-2007)

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2.8 Societal Considerations

2.9 Special Concerns

Though measles meets biological criteria to be considered a potentially eradicable disease, societal considerations also affect the feasibility of such a goal. As mentioned above, the WHA has recognized the multiple barriers to be overcome, including the challenge of vaccinating populations that are hard-to-reach due to armed conflict and changes in government.

Lack of security in some countries makes delivery of vaccinations particularly difficult, and as has been the case with mass vaccination campaigns for polio, measles eradication would require the agreement of various armed groups to allow for days of tranquillity permitting health workers to administer vaccines and follow-up with

6surveillance.

Given the high level of contagiousness of measles, interrupting transmission is further complicated by high contact rates in densely populated urban centres of the developing world. In 2008, UNFPA verified that for the first time in history more than half the world's population is living in towns and cities, and that by 2030 this number will swell to almost 5 billion, with urban growth concentrated in Africa and Asia. Interruption of transmission has yet to be demonstrated in one or more of the most rapidly expanding megacities in Africa or Asia.

During interviews and over the course of the study, several perceptions articulated as concerns were raised. They represent individual views and perceptions and are not necessarily true or correct. However, they do represent some of the issues that the Measles Initiative may need to address in future communication, information and outreach efforts. The most prominent ones are summarized below.

Measles ranks low on the list of public health priorities. Measles is no longer seen as a serious threat by parents, health care workers and governments. New parents have not experienced the anxiety of having their child suffer measles; hospitals have closed their measles wards; and governments have not had to deal with the disruption of measles outbreaks.

Another vertical disease initiative sits poorly with current global public health priorities. With emphases on health system strengthening, capacity building and country ownership and priorities, a measles eradication initiative sits poorly with the international development community providing project financing. Strategies for measles elimination and control efforts must be aligned with national priorities and strategies, which requires a special approach and effort.

There is no money in the development agency donor community. The decrease in donor funding for the Measles Initiative is indicative of the budget cuts in most development agencies, the financial crisis recovery and the lack of interest in disease specific initiatives. However, the estimated cost of measles eradication is modest (notably in comparison with the costs of global polio eradication) and an investment case could be made to a foundation or civil society partner which tends to support and own more focused disease efforts.

6‘Eradicating Measles: A Feasible Goal?’, Orenstein, Hinman & Strebel, Pediatric Health (2007)

17

The challenge of India. One has to ask oneself, if millions of people are not immunized systematically and routinely, a regional elimination goal and subsequent eradication goal would not make any sense. For an eradication effort to be effective, the government has to commit to funding and action.

The complexity of measles surveillance. While this study does not consider the epidemiological feasibility of measles eradication, a number of comments were made on that topic. One consideration of some interest was the issue of surveillance. It was argued that the clinical syndrome for measles is much less striking than e.g. that of Acute Flaccid Paralysis (AFP) and that it in order to certify the world as measles free, it would be necessary to ensure surveillance for all rash illnesses, which in turn would be hugely expensive.

Insufficient advocacy, communication and awareness in the donor and partner community. Measles has had tremendous success yet comparatively little international recognition. Without dedicated human resources and skills to effectively communicate, advocate, raise awareness, network and promote in key countries and with potential financing partners, measles eradication will not succeed. Equally importantly, the measles vaccination is encountering a high level of resistance from parents and anti-immunization groups claiming that MMR vaccines cause autism.

18

A focus on the toughest countries early in the initiative would test

tools and strategies and demonstrate it can be done.

This analysis of views clearly suggests very strong internal stakeholder commitment – notably represented by dedicated individuals in partner organizations – towards measles control efforts and a future eradication goal.

The findings of this study, however, also suggest that there is not adequate political will within donor and development agencies let alone immediate large-scale financing opportunities that would support the introduction of a measles eradication goal.

Without the necessary high level political support and up-front funding it is recommended in the short and mid-term (i.e. next 3-5 yrs) to focus on 1) generating the necessary political will and 2) mobilizing the funding required through significantly scaled up advocacy, communication and fundraising efforts.

A few opportunities to capitalize on and activities to embark upon are included below for the measles initiative to consider:

Capitalize on the unique opportunity represented by MDG 2015. With just 5 years to go to meet the MDGs and with a strong track record in reducing under five mortality, a measles initiative stands to gain a lot. It is envisaged that it would be relatively compelling for national governments and that the intervention (ideally in an integrated manner) could easily be included in national strategies and plans. However, significant advocacy and awareness raising efforts are needed.

Enhance capacity to advocate, communicate and fundraise. Repeatedly the lack of dedicated advocacy, communication and fundraising expertise was brought up as a possible explanation for the lack of international attention and awareness. Capitalizing on the experience and model of the Global Polio Eradication Initiative, the Measles Initiative is urged to consider how to deploy skilled and dedicated expertise and engage civil society leadership for country level advocacy efforts, ideally with the leadership and commitment of international civic or community level volunteers. Advocacy efforts should particularly focus on publicizing the remarkable progress to date in the fight against measles, ensuring that immunization is included as a line item in national budgets and that countries budget for SSIA activities every 3-4 years.

Strengthen the Measles Initiative. Broader partnerships, notably with the larger maternal and child health community, will be required and efforts must be made to build stronger and more linkages and relationships. Integration with other programs may represent funding and support opportunities. Measles campaigns lend themselves to integration notably with deworming, vitamin A and bed net distribution organizations and efforts (same age group and modality), and such partnerships and modalities need to be further explored.

Avoid the vertical disease control trap. At the moment, vertical disease control efforts do not resonate with the current donor and development community priorities and strategies. Integration and synergistic approaches are key success factors for a measles initiative in going forward. The documented contribution to strengthening of routine immunization and capacity building by a measles initiative has to be built into future plans.

Learn from the Global Polio Eradication Initiative The experiences of the Global Polio Eradication Initiative clearly must be used to inform a future measles eradication goal. The complexity and costs associated with ‘the last stretch’ and the difficulty in mobilizing partners to an initiative increasingly perceived as a failure strongly suggest the need for a different approach to partnership, strategy and financing. Securing all the funding up front before embarking on an eradication initiative seems imperative for it to succeed.

.

3. Recommendations and Conclusions

19

List of interviewees.

The table includes every individual to whom outreach in the form of an invitation to reply to an online survey and/or to provide input through a personal interview was sent. It includes representatives of 22 agencies, 2 foundations, 6 international organizations and 7 NGOs.

Appendix 1

No.Development or

Donor Government AgencyAffiliation

E-survey invitation

Interview invitation

Interview conducted

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

3

18

4

19

5

20

6

21

Non GovernmentalOrganizations

22

1

Foundations

1

2

International Organizations

1

2

Belgium

Brazil

Canada

CDC

CEC

Denmark

DFID

Finland

France

Germany

Ireland

Italy

Japan

Luxembourg

Netherlands

Norway

UN

Russia

UNICEF

Spain

WHO

Sweden

World Bank

Switzerland

USAID

NGO

Gates Foundation

UN Foundation

AfDB

GAVI

2

1

3

6

3

2

9

2

5

3

2

5

3

2

4

4

3

2

9

3

18

2

6

1

5

12

5

1

3

3

2

2

1

1

1

2

1

112

1

2

9

2

1

1

2

2

1

19

1

4

1

1

20

1 Australia 2 2

1. Please indicate your organizational affiliation.

Donor government/Government agency

Developing country government

International development institution

NGO

2. Please indicate your level of knowledge about measles control, elimination or eradication strategies (1 = highest, 5 = lowest)

1

2

3

4

5

3. In your opinion, how would you rank your ORGANIZATION’S support (financial and political) to a global measles eradication goal?

Highly likely

Likely

Not likely

E-survey questionnaire.

1. Introduction

This short 8-question survey seeks to establish key stakeholder interest and commitment in a future global measles eradication goal.

Kindly rest assured that your responses will be kept confidential.

Appendix 2

21

4. What would be your PERSONAL support to a global measles eradication goal?

Highly likely

Likely

Not likely

5. Please elaborate on why you personally do or do not support a global measles eradication goal.

6. If you answered ‘likely’ or ‘highly likely’ to the question above, please indicate what you consider the most important success factors to achieve global measles eradication goal.

Financial/political commitments from donor government

Financial/political commitments from other donor foundations

Achieving other eradication goals notably polio eradication

Involvement of high profile advocates and opinion leaders

Creation of community and grassroot demand

Engagement of media

Others (please specify)

Financial/political commitments from developing country/host country government

7. If you answered ‘likely’ or’ highly likely’ to question 4, please indicate how you envisage an eradication strategy to be carried out by selecting one of the following options:

A globally funded, managed and coordinated initiative along lines of e.g. Polio Eradication Initiative

22

A regionally managed and coordinated initiative

A country by country organized effort

A separate initiative

Other (please specify)

8. Please provide any comments, suggestion or reflections you may have on the idea of introducing a global measles eradication goal below.

23

E-survey analysis.

The following presents the findings from the e-survey questionnaire and replies. The survey was sent to 126 individuals of which 28 (22%) responded. The online survey was opened for input on April 30 and closed on June 14, 2010.

24 of 28 individuals or 86% provided information about their organizational affiliation.

The majority of the respondents (45.5%) represent donor governments or government agencies, including CDC, USAID, NORAD, SIDA and Government of the Netherlands.

Individuals were asked to indicate their personal level of knowledge about measles. The vast majority i. e. 82.3% of the respondents indicated that they had a ‘very high’ or ‘high’ level of knowledge about measles control, elimination or eradication strategies. 10.7% (3 individuals) indicated that their knowledge was ‘low’ or ‘very low’. These three respondents represented a government agency, a development institution and a foundation.

Appendix 3

Donor government/Government agency

International development institution

NGO

Foundation

Please indicate your organizational affiliation.

12.5%

45.8%16.7%

25.0%

1

2

3

4

5

Please indicate your level of knowledge about measles control, elimination or eradication strategies(1=highest; 5=lowest)

7.1%

7.1%

42.9%

39.3%

3.6%

24

Respondent’s responses indicated that host government and donor agency support were the most important success factors for an eradication initiative.

The respondents indicating that they had a ‘very high’ or ‘high’ level of knowledge also seemed to have a deep understanding of the complexities and range of success factors, as illustrated in the table below.

Individuals were asked to indicate if their organizations were ‘highly likely’, ‘likely’ or ‘not likely’ to support a measles eradication goal as well as indicate their personal view. 27 of 28 responded to the question related to organizational support and 26 of 28 to the question about personal support.

Respondents consider host and donor governmentcommitments as most important success factors

The most knowledgeable respondents recognizes the range of success factors of a Global Measles Initiative

Perc

enta

ge

Com

mitm

ents

from

dono

r go

vern

men

t

Com

mitm

ents

from

host

gov

ernm

ent

Com

mitm

ents

ext

erna

l d

onor

s/fo

unda

tions

Ach

ievi

ng p

olio

erad

icat

ion

Enga

ging

hig

h pr

ofile

le

ader

s/ad

voca

tes

Cre

atio

n of

co

mm

unity

dem

and

Med

ia

enga

gem

ent

70%80%

35%

50% 50% 55%

35%

Perc

enta

ge

Success Factor

1

2

5% 5% 5% 5%5%5%

5%

3

4

530% 30%

25% 15%

20%

30% 40%

15% 30%

15%

15% 25%

15%

20%

Com

mitm

ents

from

dono

r go

vern

men

t

Com

mitm

ents

from

host

gov

ernm

ent

Com

mitm

ents

ext

erna

l d

onor

s/fo

unda

tions

Ach

ievi

ng p

olio

erad

icat

ion

Enga

ging

hig

h pr

ofile

le

ader

s/ad

voca

tes

Cre

atio

n of

co

mm

unity

dem

and

Med

ia

enga

gem

ent

5% 5% 5%

25

In your opinion, how would you rank your ORGANIZATION’S and your PERSONAL support to a global measles eradication goal?

Percentage

48.1%

57.7%

22.2%

11.5%

29.6%

30.8%Not likely

Likely

Highly Likely

The respondents were asked to indicate their preferred instrument for the execution of a measles eradication strategy. All 20 individuals that had indicated that their support for measles eradication was ‘likely’ or ‘highly likely’ responded to this question. There was a clear preference (66.7%) for a globally funded managed and coordinated initiative along the lines of the Global Polio Eradication Initiative.

The results indicate some correlation between individuals not likely to support a measles eradication initiative and their perception of lack of organizational support (30.8% and 29.6% respectively).

A majority (57.7%) of the respondents indicated that they personally were in favour of a measles eradication goal.

28% of individuals indicating that they were ‘not likely’ to support a measles eradication initiative represented international donor agencies or international development institutions.

A globally funded, managed and coordinated initiatives along lines of e.g. Polio Eradication initiative

A regionally managed and coordinated initiative

A country by country organized effort

A seperate initiative

The majority of the respondents support a global, centrally managed and coordinated initiative

5.6%

66.7%22.2%

16.7%

26

Organization

Personal

It appears that there is a correlation between personal level of knowledge about the measles initiative and perception of organizational support.

28% of individuals indicating that they were ‘not likely’ to support a measles eradication initiative represented international donor agencies or international development institutions.

Perc

enta

ge

Highly likely Likely Not likely

Donor government/Government agency

International development institution

18%9%

5%

NGO

Foundation18%

18%

5%5%

23%

Significant personal resistance for a goal at Donor Agency levelPe

rcen

tage

Highly likely Likely Not likely

1

2

4% 4% 4%

The more knowledgeable about Measles, the higher likelihood of Organizational support to an initiative

(1=highest, 5=lowest level of knowledge)

3

4

5

15%

30%

11%7%

7%11%

7%

Nearly a third (30%) of individuals who indicated that their organizations were ‘highly likely’ to support the initiative also indicated that they were ‘highly knowledgeable’.

27

Summary profiles of potential partners.

The following organizations were referred to during interviews as possible partner organizations for the measles initiative to explore working with. It only represents organizations mentioned during interviews and is not to be considered as a complete or comprehensive listing.

SVI is a non-partisan, non-profit NGO which advocates for the control of both infectious diseases like measles, tetanus, pertussis, tuberculosis, and polio, and of Neglected Tropical Diseases. SVI promotes research and development of low cost vaccinations and preventable drug therapies for NTDs. SVI created the Pneumococcal Awareness Council of Experts in 2006 to raise awareness of pneumococcal disease – which kills an estimated 800,000 children a year – and to advocate for its prevention through the use of vaccines. The Institute also supports the Measles Aerosol Project, which aims to license at least one method for respiratory delivery of currently licensed measles vaccines to be used in routine immunization of children 12 - 59 months and 9 months -18 years for measles mass campaigns.

Founded in 1915 by Helen Keller and George Kessler, HKI aims to save the sight and lives of the most vulnerable by addressing the causes and consequences of blindness and malnutrition. HKI Eye Health programs address the major causes of blindness, including cataract, trachoma and onchocerciasis, and treating refractive error. Its Nutrition programs include vitamin A, iron/folate, and multi-micronutrient supplementation, fortification of commonly used foods, dietary diversification, community and school gardening as well as school health activities, the promotion of breastfeeding and complementary feeding, and nutritional surveillance to provide critical data to governments and other development partners. Specifically, in 2010 HKI has supported a national Child Health Days initiative in Zimbabwe to vaccinate 5 million children against measles. The campaign also provides children with immunizations against polio, diphtheria, pertussis and tetanus.

LCI is the world’s largest service club organization with over 45,000 clubs and more than 1.3 million members in 203 countries aiming to meet local and global needs. Lions Club programs include sight conservation (vision screenings, equipping hospitals and clinics, distributing medicine and raising awareness of eye disease), hearing and speech conservation, diabetes awareness, youth outreach (scholarships, recreation and mentoring), international relations, and environmental activities. LCI services for children involve providing immunizations through vaccination drives, vision and hearing screening, nutritional programs for undernourished children, securing wheelchairs for disabled children, and constructing hospitals, schools, orphanages and children’s centres. In the Philippines, for example, the Digos City club members helped government healthcare workers provide 25,000 measles vaccines and distribute 17,600 Vitamin A tablets to local children.

An international, coeducational service club founded in 1915, Kiwanis comprises 8,000 clubs in 96 countries with over 260,000 adult members. Members serve children and youth using two approaches: improving the quality of life directly through activities promoting health and education, and encouraging leadership and service among youth. Specifically, Young Children Priority One (YCPO) is an ongoing community service program of

Sabin Vaccine Institute (SVI)

Helen Keller International (HKI)

Lions Clubs International (LCI)

Kiwanis International

Appendix 4

28

Kiwanis that addresses the needs of children 0-5 and includes a focus on maternal and child health. All clubs are encouraged to carry out at least two YCPO projects per year. Kiwanis is partnered with the Boys and Girls Scouts Clubs of America, the Children's Miracle Network, the March of Dimes and UNICEF, for which it raised nearly $5 million for Iodine deficiency programs worldwide and HIV and AIDS programs in Kenya and Swaziland. Currently, Kiwanis and UNICEF have partnered to raise US $1. 5 million to benefit Uruguay, and Kiwanis participate annually in Saving Lives: The Six Cents Initiative to supply clean water and sanitation to children worldwide.

GAVI was launched at the 2000 World Economic Forum to reduce childhood morbidity and mortality from vaccine preventable diseases by increasing immunization rates and improving vaccine access for children in developing countries. The GAVI Fund provides financial support to low-income countries, based upon applications to and recommendations by the GAVI Alliance Board. GAVI partners include developed country vaccine manufacturers (Crucell, GlaxoSmithKline, Merck & Co., Inc. , Novartis, Sanofi Pasteur, the vaccines division of sanofi-aventis, and Wyeth), developing countries vaccine industry, industrialized and developing country governments, UNICEF, the WHO, the World Bank, charitable organizations like the Bill & Melinda Gates Foundation, and NGOs. GAVI has enabled 250 million children to be vaccinated and has averted 5 million early deaths. In particular, GAVI supports global measles second dose vaccination if it is included in the country's comprehensive multi-year plan. In 2007 the UN Foundation received $139 million from GAVI to support the Measles Initiative in reducing measles deaths by 90 percent by 2010, a contribution made through the International Finance Facility for Immunisation initiative.

The Federation – which aims to “improve the lives of vulnerable people by mobilizing the power of humanity” – leads and organizes, in cooperation with the National Societies, international relief assistance missions responding to large-scale emergencies. Its Health and care activities are diverse and include first aid and emergency response as well as epidemic control, programmes in health promotion and prevention, addressing stigma, providing psychosocial care and enabling community empowerment. The Federation's secretariat chairs the Alliance for Malaria Prevention (AMP), a subgroup of the Roll Back Malaria Partnership which includes more than 20 partners. The AMP support Ministries of Health to deliver long lasting insecticide treated nets (LLINs) to vulnerable groups via mass delivery in conjunction with other child survival campaigns. These include vaccination campaigns for measles or polio, Vitamin A supplementation, deworming, and bi-annual mother child health weeks.

Established in 1976 by the sons of King Faisal of Saudi Arabia, the Foundation focuses on health, education, research, and the development of the individual, with attention also focused on the various aspects of Islamic culture. It presents an annual international prize to “dedicated men and women whose contributions make a positive difference” in the areas of service to Islam, Islamic studies, Arabic Language and literature, Science and Medicine. The categories of Science and Medicine encourage decisive advances in areas which benefit mankind in general and the most needy nations in particular, including infertility, prevention of blindness, schistosomiasis and acquired immunodeficiency diseases. The associated King Faisal Center for Research and Islamic Studies serves Islamic civilization, supports continuing research, and encourages various cultural and scientific activities.

GAVI Alliance

International Federation of Red Cross and Red Crescent Societies

King Faisal Foundation

29

Merck & Co. , Inc.

GlaxoSmithKline (GSK)

The Serum Institute of India

Sanofi Pasteur

7

Also known as Merck Sharp & Dohme outside the US and Canada, Merck & Co., Inc is one of the seven largest pharmaceutical companies in the world both by market capitalization and revenue. It discovers, develops, manufactures and markets vaccines and medicines and publishes health info as a not-for-profit service. As part of its support for the GAVI Alliance, the Merck Company Foundation funds the Merck Vaccine Network - Africa. Merck also provided 1 million doses of MMR II vaccine for mumps, measles and rubella to Honduras over a three-year period and donated hepatitis B vaccine in support of GAVI. Merck is also providing rotavirus vaccination for all infants in Nicaragua for a three-year period. In 2008, Merck contributed USD 2 million to the GAVI-supported Measles Initiative of the UN Foundation, for disease surveillance activities in Africa. Since 2001, the Measles Initiative has supported the vaccination of more than 600 million children in more than 60 countries.

Headquartered in the UK and with operations based in the US, GSK is a research-based pharmaceutical company with an estimated 7% share of the world’s pharmaceutical market. It is committed to tackling the three “priority” diseases identified by the WHO: HIV/AIDS, tuberculosis and malaria. It delivered 1. 4 billion vaccine doses in 2009, of which nearly 1 billion were shipped for use in developing countries. The WHO and UNICEF developed Integrated Management of Childhood Illness (IMCI) as an improved delivery strategy for child survival interventions. GSK has been involved with IMCI since 1996 when it initiated a partnership with the South African Ministry of Health. Since then, GSK has entered into public-private partnership agreements with WHO, UNICEF, National Ministries of Health and/or NGOs for the implementation of the IMCI strategy or components thereof in Ethiopia, Namibia, Nigeria, Ghana and Kenya. IMCI aims to reduce morbidity and mortality due to the major killer diseases for children under five: malaria, diarrhea, malnutrition, measles, pneumonia, HIV/AIDS and neonatal causes. The strategy includes three main components: 1) improving the case management skills of health workers; 2) strengthening the health system; and 3) improving key household and community practices that have the greatest impact on child survival.

The Serum Institute of India is a manufacturer of immunobiologicals including vaccines in India. Half the children in the world are immunized by vaccines made by the company, which is the world’s biggest maker of measles and DTP vaccines. It produces a billion doses a year selling in 140 countries, and is one of the world's lowest cost producers of vaccines.

Sanofi Pasteur, the vaccines division of sanofi-aventis Group, is the largest company in the world devoted entirely to human vaccines. Sanofi Pasteur supports GAVI’s polio eradication efforts and has donated 120 million doses of oral polio vaccine (OPV) since 1997. It also supports the GAVI Yellow fever vaccine initiative for Africa. In 2007, Sanofi Pasteur sponsored the first EPIVAC technical conference on yellow fever, which drew 150 participants from Benin, Burkina Faso, Cameroon, Côte d’Ivoire, Guinea, Mali, Senegal and Togo.

30

7Merck & Co., Inc. ,Whitehouse Station, USA and Merck KGaA, Darmstadt, Germany are two independent companies. Merck & Co., Inc. operates as Merck Sharp & Dohme (MSD) outside the USA and Canada, while Merck KGaA is represented by EMD Serono, Inc in the USA and Canada

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