In one of China’s poorer western provinces, a middle-aged woman suffers from flu-like symptoms. She delays seeking medical attention due to the costs of transportation and of medicine. By the time she receives care, it will be too late—her symptoms signal not influenza but advanced liver cancer, caused by the hepatitis B (hep B) virus. She will live just a few months, at most a few years.
Her story is far too common in China, home to the largest burden of hep B in the world. Of the 350 million people living with chronic hep B, three-quarters reside in Asia and the Western Pacific.source Hep B is endemic in China, and most Chinese become infected when they are young. As a result, 93 million Chinese carry the chronic hep B infection, causing 250,000 to 300,000 hep B–associated liver cancer deaths every year.source Although there are treatments for diseases caused by hep B, they are often unavailable where hep B is prevalent and costly. The road to hep B control therefore lies in prevention.
Beginning in 1992 and intensifying in 2002, China mounted a hep B prevention campaign, rolling out the vaccine across the country. But a financial barrier kept the vaccine out of reach of most of the people in the poorer parts of China. The government of China partnered with Gavi, the Vaccine Alliance, to reduce this inequity, extending the reach of hep B prevention to underserved communities. By channeling funding and health system resources to those at risk, the prevention program eventually overcame numerous obstacles to achieve a tremendous impact: a nationwide decrease in childhood hep B prevalence from nearly 10 percent in 1992 to less than 1 percent in 2006.source A credible modeling exercise suggests that the government vaccination program prevented about 3.8 million chronic hep B infections between 2003 and 2009 in program areas, averting roughly 680,000 future deaths.source
Gavi and the government of China provided joint support for the roughly $76 million investment. And a costing exercise over the period from 2003 to 2007 strongly supports the program’s cost-ffectiveness. The program cost just US$28.70 per chronic hep B infection prevented and US$160 per future hep B death averted.source
As a model for public health prevention, the China-Gavi Program offers relevant operational lessons on how to tackle inequity by building bridges between underserved people and lifesaving technologies.
The China-Gavi Program built on existing Chinese government hep B vaccination efforts, considerably extending the preexisting program’s reach. National commitment to the China-Gavi Program and focused attention on the most underserved areas were critical to its success. As were its innovative strategy to procure vaccines and syringes from local suppliers, which helped increase the program’s cost-effectiveness, and the program’s management setup inside China’s National Immunization Program.
The China-Gavi experience illustrates how a relatively short-term program can catalyze large-scale change and national commitment. It also sheds light on how global health funders like Gavi can leverage their comparative advantages to achieve massive impact in middle-income countries. Gavi support—by providing a modest amount of resources for activities—stimulated policy changes on fees and the regulation of domestic manufacturing. These lessons may aid the rollout of other “new generation” vaccines, such as for pneumococcal disease, in countries that will also soon graduate from Gavi support.