Global support for new vaccine implementation in middle-income countries.

Middle-income countries (MICs) as a group are not only characterized by a wide range of gross national income (GNI) per capita (US $1026 to $12,475), but also by diversity in size, geography, governance, and infrastructure. They include the largest and smallest countries of the world-including 16 landlocked developing countries, 27 small island developing states, and 17 least developed countries-and have a significant diversity in burden of vaccine-preventable diseases. Given the growth in the number of MICs and their considerable domestic income disparities, they are now home to the greatest proportion of the world's poor, having more inhabitants below the poverty line than low-income countries (LICs). However, they have little or no access to external funding for the implementation of new vaccines, nor are they benefiting from an enabling global environment. The MICs are thus not sustainably introducing new life-saving vaccines at the same rate as donor-funded LICs or wealthier countries. The global community, through World Health Assembly resolutions and the inclusion of MIC issues in several recent studies and important documents-including the Global Vaccine Action Plan (GVAP) for the Decade of Vaccines-has acknowledged the sub-optimal situations in some MICs and is actively seeking to enhance the situation by expanding support to these countries. This report documents some of the activities already going on in a subset of MICs, including strengthening of national regulatory authorities and national immunization technical advisory groups, and development of comprehensive multi-year plans. However, some additional tools developed for LICs could prove useful to MICs and thus should be adapted for use by them. In addition, new approaches need to be developed to support MIC-specific needs. It is clear that no one solution will address the needs of this diverse group. We suggest tailored interventions in the four categories of evidence and capacity-building, policy and advocacy, financing, and procurement and supply chain. For MICs to have comparable rates of introduction as other wealthier countries and to contribute to the global fight against vaccine-preventable diseases, global partners must implement a coordinated and pragmatic intervention strategy in accord with their competitive advantage. This will require political will, joint planning, and additional modest funding.