February 8, 2022

The Case for Improved Global Governance of Vaccination Hesitancy and Vaccine Procurement

A paper that assembles the case for enhanced global governance of vaccination hesitancy and vaccine procurement.

The Case for Improved Global Governance of Vaccination Hesitancy and Vaccine Procurement

Done By: He Shiying (November 2019)

In 1980, the World Health Assembly declared the successful eradication of smallpox, bringing an end to a fatal disease that caused an annual 500 million infections and 2 million deaths worldwide (World Health Assembly 1980). Such an incredible feat depended upon 21 years of collaboration between key international organisations, all countries, international non-governmental organisations and health professionals, and had elevated vaccination as key to enhancing global health (Fenner et al. 1988). Vaccination has prevented at least 10 million deaths between 2010 and 2015, with millions protected from severely debilitating diseases such as polio, measles, pertussis, and pneumonia (Strategic Advisory Group of Experts on Immunization 2018). Not only do vaccines directly improve population health outcomes, nations also reap massive gains in productivity and economic growth (World Economic Forum 2018). Yet, despite global efforts to ensure universal access to immunization since 1974, it remains a faraway goal. As the end of the most recent Global Vaccine Action Plan (GVAP) approaches in 2020, more than 19 million children still lack access to basic immunization, overall progress on vaccination coverage across the globe has stagnated, with any progress made thus severely threatened by backsliding in the wake of emerging global challenges that current global governance efforts seem ill-equipped to handle (Strategic Advisory Group of Experts on Immunization 2018). This paper highlights two of such challenges, namely poor governance of the global vaccine supply and the rise of vaccine hesitancy. In order to ensure universal access to immunization, there is an urgent need for global governance to address both gaps.

The first gap in the global governance of vaccination is poor global management of vaccine supply. The GVAP aimed the number of countries experiencing stockouts at 25 countries or less by 2020, but the current number laid far behind at 65 in 2015, revealing little improvement since pre-GVAP levels in 2010 (Lydon et al. 2017). A study found that one-third of WHO Member States had experienced at least one vaccine stockout for at least one month”, with Sub-Saharan African countries and middle-income countries experiencing the worst of stockouts (Lydon et al. 2017). The primary reasons for stockouts were delayed government funding, delayed procurement and poor forecasting and stock management. Such dismal results persist despite procurement aid and knowledge exchange from the WHO, UNICEF, Global Alliance for Vaccines and Immunization (Gavi), the World Bank and initiatives such as the WHO Vaccine Product, Price and Procurement (V3P) project and Vaccine Procurement Practitioners Network (World Health Organization 2019; n.d.).  Apart from stockouts, more vaccines globally are wasted every year because of poor logistics and cold chain management (World Economic Forum 2018). When vaccine supply is compromised, trust in immunization programmes become undermined and the health of the most vulnerable becomes threatened (Lydon et al. 2017).

The second gap in the global governance of vaccination is insufficient attention on the rise of vaccine hesitancy. Vaccine hesitancy is defined as the “delay in acceptance or refusal of vaccines despite availability of vaccination services” (Eskola et al. 2015). The GVAP aimed to eliminate measles in at least five out of six WHO regions by 2020. However, 2019 saw the highest number of measles reported since 2006 (Lobley 2019). Significant measles outbreaks had occurred in four out of six WHO regions in the past three years, including countries such as the US, Japan and Germany with histories of good vaccination coverage and had previously been declared measles-free (Nature Medicine 2019; Wamsley 2019). Vaccine hesitancy is driven by government complacency, inconvenience of vaccination and declining confidence in vaccines, with the last being perpetuated by vaccine misinformation. Vaccine hesitancy is a threat to global health because vaccine-preventable disease are highly contagious. Several cases in Japan were linked to citizens returning from the Philippines while outbreaks in the US were linked to returning citizens from France, Israel and Ukraine (Wamsley 2019). Apart from the launch of a Strategic Advisory Group of Experts (SAGE) on Immunization Working Group on vaccine hesitancy (Larson et al, 2014), little interventions were introduced despite calls for global collective action on measuring and quelling vaccine hesitancy from as early as 2011 (Larson et al. 2011). It was only this year when vaccine hesitancy had been recognised one of WHO’s top ten threats to global health, and when the first Global Vaccination Summit was organised, which had merely called for global action against the spread of misinformation (World Health Organization and European Commission 2019).  

Photo by Kyle Glenn on Unsplash

In order to address poor global management of vaccine supply, more can be done at the regional level. MICs can develop cross-border group purchasing organisations (GPOs) akin to that of the Pan American Health Organization (PAHO) Revolving Fund, which has  substantially reduced cost of vaccine products for its 41 member states (Tirso 2014). Doing so can greatly reduce costs of key vaccines to overcome problems of insufficient government funding as MICs transition away from reliance on donor aid. Further, the 19 million children that lack access to vaccines are often located in resource-poor regions, where innovations in logistics and cold chain management are desperately needed to overcome local energy shortages to reduce wastage (World Economic Forum 2018; Strategic Advisory Group of Experts on Immunization 2018). Investments in innovations that reduce vaccine wastage should be channeled to regional vaccine manufacturers, which in turn ultimately increases local capacity, cost savings and health outcomes in the long run.

Next, in order to address vaccine hesitancy, there is an urgent need to reinforce vaccination’s role in development and target the spread of misinformation at the global, regional and national levels. While hard laws such as treaties usually have little to no improvement on health outcomes, studies have shown that including institutional mechanisms such as automatic penalties and sanctions, mandated regular reporting and compliance assessments can increase their effectiveness (Hoffman and Røttingen 2015). Hence, the next GVAP from 2020 onwards should be a legally binding treaty that frames vaccination as a basic human right with the aforementioned institutional mechanisms incorporated (Gostin et al. 2013; Hoffman and Røttingen 2015). A formalised treaty exerts institutional power that can empower NGOs and all stakeholders in health systems to hold political leaders accountable, similar to the mechanism by which studies on The WHO Framework Convention on Tobacco Control’s found that the treaty and its negotiation process were associated with stronger adoption of tobacco control measures in ratifying countries (Craig et al. 2019). Not forgetting the crucial role the web plays in disseminating vaccination-related information, public-private partnerships must be established with social networking sites to curb the spread of misinformation. The president of the American Academy of Paediatrics, Kyle Yasuda, had successfully engaged with Facebook to remove anti-vaccine misinformation from selected algorithms (The Lancet Child & Adolescent Health 2019). However, since more remains to be done on Facebook and other social media sites, the treaty can leverage on its enforcement mechanisms to mandate Member States to form similar public-private partnerships adapted to regional and national needs. At the regional level, organisations such as the Regional Immunisation Technical Advisory Groups (NITAGS) play a crucial role in exerting pressure on international organisations to hold relevant conferences such as the Global Vaccination Summit in LMICs to allow equal opportunity to key stakeholders in LMICs to easily engage in the decision-making process. Alongside NITAGS, NGOs like the Bill and Melinda Gates Foundation are also in the prime position to engage the expertise of social scientists, experts in social marketing and communication and diseases to address the multi-disciplinary nature of vaccine hesitancy at the grassroots level.

Lauded as the most cost-effective intervention to dramatically improve health outcomes, vaccination lies at the heart of healthcare. Despite having made great strides in vaccine coverage in the developed world, much of the developing world still lack access to the most fundamental vaccines. At the same time, vaccine hesitancy has finally reared its ugly head, bringing about widespread measles outbreaks across both the developed and developing world, threatening to reverse decades of progress. The path to universal vaccination coverage demands for improved governance of the global vaccine supply though the formation of cross border GPOs and investments in innovations that increase the capacity of local health systems. Further, vaccine hesitancy signals the need for the reemphasis of vaccination’s importance through a legally-binding treaty and engagement with private actors as well as actors beyond those in science and technology. It is only with governance at the global, regional and national levels can the world effectively prevent cross-border spread of vaccine-preventable diseases, ensure universal access to vaccination services and ultimately promote better health outcomes across the globe.

No. of words (excluding citations): 1337.


Craig, Lorraine, Geoffrey T Fong, Janet Chung-Hall, and Pekka Puska. 2019. “Impact of the WHO FCTC on Tobacco Control: Perspectives from Stakeholders in 12 Countries.” Tobacco Control 28 (Suppl 2): s129–35. https://doi.org/10.1136/tobaccocontrol-2019-054940.

Eskola, Juhani, Philippe Duclos, Melanie Schuster, and Noni E. MacDonald. 2015. “How to Deal with Vaccine Hesitancy?” Vaccine 33 (34): 4215–17. https://doi.org/10.1016/j.vaccine.2015.04.043.

Fenner, F, D. A Henderson, I Arita, Z Ježek, and I. D Ladnyi. 1988. Smallpox and Its Eradication. Switzerland: World Health Organization.

Gostin, Lawrence O, Eric A Friedman, Kent Buse, Attiya Waris, Moses Mulumba, Mayowa Joel, Lola Dare, Ames Dhai, and Devi Sridhar. 2013. “Towards a Framework Convention on Global Health.” Bulletin of the World Health Organization 91 (10): 790–93. https://doi.org/10.2471/BLT.12.114447.

Hoffman, Steven J., and John-Arne Røttingen. 2015. “Assessing the Expected Impact of Global Health Treaties: Evidence From 90 Quantitative Evaluations.” American Journal of Public Health 105 (1): 26–40. https://doi.org/10.2105/AJPH.2014.302085.

Larson, Heidi J., Louis Z. Cooper, Juhani Eskola, Samuel L. Katz, and Scott Ratzan. 2011. “Addressing the Vaccine Confidence Gap.” Lancet (London, England) 378 (9790): 526–35. https://doi.org/10.1016/S0140-6736(11)60678-8.

Lobley, Rosemary. 2019. “Benefits of Vaccines Highlighted at Global Vaccination Summit.” Health Europa, September 12, 2019. https://www.healtheuropa.eu/benefits-of-vaccines-highlighted/93282/.

Lydon, Patrick, Benjamin Schreiber, Aurelia Gasca, Laure Dumolard, Daniela Urfer, and Kamel Senouci. 2017. “Vaccine Stockouts around the World: Are Essential Vaccines Always Available When Needed?” Vaccine 35 (17): 2121–26. https://doi.org/10.1016/j.vaccine.2016.12.071.

Nature Medicine. 2019. “Time to Vaccinate against Hesitancy.” Nature Medicine 25 (7): 1023–1023. https://doi.org/10.1038/s41591-019-0524-1.

Strategic Advisory Group of Experts on Immunization. 2018. “2018 Assessment Report of the Global Vaccine Action Plan.” Switzerland: Geneva: World Health Organization.

The Lancet Child & Adolescent Health. 2019. “Vaccine Hesitancy: A Generation at Risk.” The Lancet Child & Adolescent Health 3 (5): 281. https://doi.org/10.1016/S2352-4642(19)30092-6.

Tirso, Carilu Pacis. 2014. “PAHO Revolving Fund.” Pan American Health Organization / World Health Organization. May 9, 2014. https://www.paho.org/hq/index.php?option=com_content&view=article&id=1864:paho-revolving-fund&Itemid=4135&lang=en.

Wamsley, Laurel. 2019. “Measles Is Spiking Around The Globe. How Worried Should We Be?” NPR, December 3, 2019. https://www.npr.org/sections/goatsandsoda/2019/03/12/697928724/measles-is-spiking-around-the-globe-how-worried-should-we-be.

World Economic Forum. 2018. “Over Half of Vaccines Are Wasted Globally for These Simple Reasons.” World Economic Forum. July 24, 2018. https://www.weforum.org/agenda/2018/07/the-biggest-hurdle-to-universal-vaccination-might-just-be-a-fridge/.

World Health Assembly. 1980. “Global Smallpox Eradication.” World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/155528/WHA33_R3_eng.pdf?sequence=1&isAllowed=y.

World Health Organization. 2019. “MI4A: Market Information for Access to Vaccines.” WHO. August 2019. http://www.who.int/immunization/programmes_systems/procurement/mi4a/platform/en/.

———. n.d. “Resource Gateway: UNICEF Vaccine Procurement Information.” WHO: Immunization, Vaccines and Biologicals. Accessed November 6, 2019. http://www.who.int/immunization/programmes_systems/procurement/mi4a/platform/module3/procurement_information/en/.

World Health Organization, and European Commission. 2019. “Global Vaccination Summit: Ten Actions Towards Vaccination For All.” Brussels. https://ec.europa.eu/health/sites/health/files/vaccination/docs/10actions_en.pdf.

Stay updated on the best insights from public health professionals.

Powered by EmailOctopus