Till only a few years ago we Pediatricians used to vaccinate the children against mainly the six killer diseases covered under UIP (Universal Immunization Programme) namely Tuberculosis, Diphtheria, Pertussis, Tetanus, Polio and Measles. To a large extent these vaccines were supplied by the Government Health Agencies. Some practitioners purchased them from the market but these vaccines were, by and large, very economical with the exception of MMR. However, the scene has changed rapidly in the ninetees. Imported vaccines for Typhoid, Hepatitis Band Haemophilus influenzae b (Hib) have been introduced for childhood immunization. These vaccines coming from different manufacturers and targeting various micro-organisms have only one thing in common-all are exhorbitantly costly.

Indian middle class parents, whose aspirations for their children are high but average incomes much lower than their counterparts in developed and even many developing countries are confounded by this phenomenon of ever increasing list of vaccinations required by their children. Every time they want to believe their children are fully vaccinated, a new vaccine is added to the list. Their position could not be more unenviable. Beside the cost of privatized school education, medical treatment, and decent living this is another expenditure for which now they have to wear their belts. even tighter. Moreover, this trend is likely to continue and more vaccines will be added to children's immunization list in coming years. Such a scenario has never existed before. Some Pediatricians may find it tricky to go about this issue. Those practicing in low income group pockets will certainly do so.

Some critics have even raised doubts whether increasing use of these costly vaccines is due to a hype created by doctors and multinational companies for financial gains. These doubts as we know are base- less of course. These vaccines do a lot of good to the children vaccinated and effectively bring down the incidence of disease in the society. But justifying the vaccines does not solve the basic problem, i.e., high cost versus low affordability.

Although this problem can not be solved overnight there is need to take appropriate measures. Pediatricians should by all means inform the parents about the benefits of vaccines. They can be mildly persuasive with parents who can afford it but in no case they should be coercive or harshly critical of the parents who are delaying the vaccination for financial reasons. They should avoid giving poor parents a guilt complex. After all in a country where Malaria and Tuberculosis are gulping lives by the thousands, parents can hardly be blamed if names like Hib and Hepatitis B do not catch their imagination.

At the same time, Pediatricians should always strive to find cheaper yet safe and effective options. For example Hepatitis B vaccination can be made much more economical if serum derived vaccine (which has been declared safe and effective by both WHO and UNICEF) is used. Of all the imported vaccines Hepatitis B should get first priority. The Government of India, instead of remaining a silent spectator to this tricky situation should intervene. It should prevail upon multinational companies to make these vaccines available at cost price. Multinational companies could charge developed countries a price that gives a return on the cost of developing and producing the vaccine. It should take the help of Children's Vaccine Initiative which could collaborate with the developed countries, World Bank, WHO and others to reduce the price of new vaccines to developing countries. At the same time India, the second most populous country in the world with huge consumption of vaccines should make efforts towards indigenous production of newer vaccines.
 

Mukul Tiwari,
Apex Child-Mother General
Hospital and Research Centre,
University Road, Thatipur,
Gwalior, Madhya Pradesh,
India.

 

Dr. Tiwari has identified and highlighted a very important and contemporary problem in India's public health system. He reminds us that till recently we were giving only six vaccines routinely and to a large extent all of them were supplied by Government Health Department free of cost. Even when purchased from the market, these vaccines were quite inexpensive. Vaccines not included in the Expanded or Universal Immunization Programme (UIP) are very costly. They include Measles MurnpsIubella (MMR), new Typhoid fever vaccines, and those against Hepatitis Band Haemophilus influenzae type b. the doctor's dilemma is whether to promote these newer vaccines which will pinch the purse of parents and increase the profit of the producers, or, not to promote them whereby the children will be denied the benefit of protection from preventable pathology.

Cost and cost alone is the main issue here. Sympathizing with middle and low income parents, Dr. Tiwari points out that both education and medical care in the private sector are already very expensive and to this we are adding more expense for several new vaccines. The baby should not be thrown out along with the bath water; we need the already licensed and other anticipated new vaccines for the health and well being of our children, but we must look for ways and means of reducing the cost burden. We must examine the suggested as well as any other innovative ways to make available all good vaccines at fair prices. There are some steps each one of us could take. We may take some steps collectively. There are other options over which we may have very little control, but we can enunciate them and seek support from the Government.

Individually, we must examine how we can minimize the cost of immunization with these expensive vaccines. Some marketing agencies offer lower prices if larger volumes are purchased. Institutions can certainly make use of such offers and pass on the benefit to the parents. Individual practitioners may not be able to purchase such large quantities, but if several persons join together, this approach is worth exploring. In the case of certain vaccines, there may be more than one brand and we could choose the product which costs less, provided quality is not compromised. The cost to the family includes the cost of the vaccine plus the service charge of the doctor. There is a hearsay information that in some places the doctors hike up the service charge for these expensive vaccines on the excuse that families who could afford the vaccine can also afford a proportional ser- vice charge. This aspect is for each of us to ponder over and come to a decision, but I will certainly argue for the minimum of doctor's charges only to recover the cost of the syringe and needle and for giving immunization on a no profit no loss basis as a public service, especially for children of the families who attend the doctor's clinic regularly for all illnesses. If that is not feasible, at least to charge only a nominal and minimal fee. To charge the same consultation fee for giving each dose of immunization as for a sick visit is not appropriate, in my view.

Collectively we must put pressure on marketing agencies to reduce their advertising expenses and pass on the saving to the purchasers of vaccines. If all of us agree, we can politely tell vaccine distributors that we do not want" gifts" from them if they will reduce price. But before we can tell this to suppliers, we must be clear that we will also try to minimize our charges to the families. Regarding Hepatitis B vaccine, there is the potential to reduce price drastically, for which the government public health system must play the major role. If approved for routine immunization and bulk ordered, the manufacturers will no longer need to stock it at their risk nor to advertise vigorously. Under these circum- stances we should be able to obtain hepatitis B vaccine at the price of less than 40 rupees (that is, less than a dollar) per dose as several other countries have been able to manage. I understand that UNICEF global tender system purchases it for less than a dollar a dose. The suggestion made by Dr. Tiwari that companies can sell at their regular market prices in developed countries and at lower prices to developing countries is not new; indeed this "tier pricing" system is what makes oral polio vaccine cheap in our countries, while it costs many times more in rich countries.

Will indigenous production necessarily reduce vaccine prices? In some cases yes, and in others no. If a vaccine technology is under patent protection, then indigenous manufacture is not possible unless the technology is purchased, which will make the cost of production. quite high. For those vaccines not under patent, local manufacture should be economical. The ideal way is to begin with the research towards vaccine development in which case we should be able to produce vaccines at low cost, but only over the long term. That has been the policy of China which has been self sufficient for nearly all vaccines. India and China established OPV manufacturing units and India decided to close down the one and only successful production unit while China expanded production by establishing additional units. So they were able to control and eliminate poliomyelitis way ahead of 1.).S. We were constrained by the need to import all polio vaccine thereby behaving stingy with the number of doses until 1995 when we have started pulse immunization, for which we pay dearly for . the vaccine. China manufactures their own hepatitis B vaccine; they also have their own production of hepatitis A vaccine as well as both live and killed Japanese encephalitis vaccines. In all these, little foreign exchange flows out of the country for vaccine purchase, but we have not been far sighted enough with the health of our children, nor the need to conserve our currency while boosting employment and internal circulation of cash. China even got Rotary International Polio Plus grant assistance to manufacture OPV while India has not even been allowed to establish a vaccine production unit after we closed down the existing one. To become rich one must invest, not merely accumulate. India had another manufacturing unit built to make Vero cell based rabies vaccine and measles vaccine along with Salk polio vaccine, but once again our government decided to close it down. Every one knows all these and India is a dream market for foreign manufacturers of the new vaccines. Today we talk about Hepatitis B and Hib vaccines but tomorrow there will be Hepatitis A and Varicella vaccines and the day after, Rotavirus and Pneumococcal conjugate vaccines and in all like1i.1;100d Respiratory Syncytial Virus vaccine and Dengue Vaccine on our immunization schedule. Modem Typhoid fever vaccines, cell culture rabies vaccines and Japanese Encephalitis vaccine are also essential in our country. I have personally tried and continue to try my best to enlighten the government on our need to take a long term view on these matters and to develop policy guidelines. However, health is not of high priority in our country. Collectively we must keep up the pressure on both the leaders and the public to take these matters seriously.
 

T. Jacob John,
Chairman,
lAP Committee on Immunization
 and President Elect,
Thekkekara,
2/91 E2 Kamalakshipuram,
Vellore, Tamilnadu - 632 002,
India.