After decades of research and development, two new malaria vaccines entered routine administration this year. This is a huge win for science, and potentially for humanity. Gavi, the Vaccine Alliance, projects that these vaccines will save 180,000 children’s lives by 2030.
But over the same time period, even after all the global expenditure on bed nets and malaria drugs, roughly 2.5 million children will die of malaria unvaccinated. We now have a new technology that could save about a third of those kids – roughly 800,000 additional child deaths that could be averted with vaccines by 2030, but won’t be under current plans for a gradual rollout.
Quantitatively, that’s equivalent to every single child alive today under age 5 in Washington DC, Maryland, and Virginia dying while we sit by and watch.
What are we waiting for?
Over the past several months, we’ve traveled to Nigeria, the Democratic Republic of Congo, Mozambique, and Malawi, and asked this question to government officials, staff at Gavi, the WHO, and the US President’s Malaria Initiative, and international NGOs like PATH. We wrote up what we’ve learned in a new CGD policy paper, but here’s the shorter version.
Money, obviously
Gavi expects to vaccinate 52 million children against malaria by 2030, at a total cost of about $1.4 billion. That’s a lot, but also not nearly enough.
In just the 20 countries with the highest malaria incidence, where there’s a strong case for nearly national coverage, the number of infants potentially eligible to be vaccinated by 2030 is around 140 million, nearly triple Gavi’s plans. Those extra doses would cost somewhere in the ballpark of another $1.1 billion; adding in older kids still technically eligible per the WHO would raise the price tag closer to $1.7 billion.
Check out the flourish chart at https://flo.uri.sh/visualisation/19953469/embed?auto=1
But that only covers the cost of vaccines.
Actually getting shots in arms will require spending on the last-mile challenges of vaccine rollout too. The Democratic Republic of Congo, for instance, needs to distribute a new, unknown vaccine across a country the size of Western Europe, most of which has no paved roads and no electric grid. The cold chain needs to be strengthened. Health workers need to be trained. Communities need to be told what’s going on, and encouraged to come get vaccinated.
Large-scale WHO malaria vaccine pilots in Ghana, Kenya, and Malawi dramatically reduced child mortality. But they spent about $2.75 per dose on rollout, above and beyond the vaccines themselves. Taking that as a model, countries would need to find another $500 million to actually implement immunization with the vaccines Gavi has already committed to purchasing. A more ambitious rollout, covering all eligible infants or all eligible kids under age 3 would push the funding gap for vaccine rollout up to roughly equal to the funding gap for vaccines themselves.
The price tag of $2.75 per dose for rollout is probably far too high – national scale-up will have to make do with much less than the WHO pilots, but these numbers give a sense of financial obstacles countries face.
Cheaper, more plentiful R21 vs RTS,S
Keeping those costs under control will require pursuing value for money with scarce resources. On that front, a key sticking point in malaria vaccine policy debates to date has been the choice of which vaccine to back.
We spend a couple thousand words on this in the paper, but the short version is this:
- Per the WHO, the two vaccines appear very similar in terms of effectiveness. We would probably say that, if anything, R21 has a slight edge in current data, but RTS,S has undergone more testing over longer time horizons.
- R21 is much cheaper, at about $3.90 per dose versus $9.80 per dose for GSK’s branded RTS,S vaccine. Both require four doses.
- Furthermore, the short- to medium-run supply of R21 is much greater. India’s Serum Institute has basically said it can supply the world on short notice, it’s just waiting for the orders.
Table: Comparison of the two malaria vaccines with WHO prequalification
| RTS,S | R21 | |
|---|---|---|
| Vaccine efficacy against clinical malaria in perennial (i.e. non-seasonal) sites in children aged 5-17 months | ||
| 12 months | 56% | 75% |
| 32 months | 44% | Not yet known |
| 48 months | 36% | Not yet known |
| Production | GSK | Serum Institute |
| Production capacity | ~8 million doses/year | ~100 million doses/year |
| Price per dose (x4 doses) | $9.81 | $3.90 |
| Estimated cost per life saved* | $11,800 | $4,200 |
Sources: See Duncombe, Elabd, and Sandefur (2024) for full details. Vaccine efficacy numbers are taken from published results of stage 3 clinical trials. Estimated cost per life saved is based on published modeling estimates, adjusted for the current price of each vaccine plus allowance for additional rollout costs (assumed to be equal for the two vaccines). In the case of RTS,S model estimates are the average of the Swiss Tropical and Public Health/Telethon Kids Institute model and the Imperial College model; in the case of R21 they are based on the Imperial College model.
Building on published model estimates, and allowing for the full cost of vaccines and ample budget for rollout, we estimate that R21 will save one life per $4,200 spent, rivaling some of the best buys in global health.
Several African countries have been in a tug-of-war with Gavi, demanding access to R21 instead of RTS,S. It appears that dispute is largely resolved, mostly by Gavi allocating R21 doses to countries with higher co-financing requirements and deploying RTS,S in places where Gavi will cover the extra cost. But even if Gavi is footing the bill, total resources remain scarce. Any ambitious plan to vaccinate all kids at risk of severe malaria requires prioritizing R21.
The Nigerian elephant in the room
A third of all malaria deaths worldwide are in Nigeria. But the Nigerian government spends just $10 per capita on health, total. That makes the price of malaria vaccines – at over $15 per child for four doses, plus rollout costs – prohibitively expensive.
This is where international aid from agencies like Gavi would normally fill the gap. But with a per capita GNI of $1,930 in 2023 according to the World Bank, Nigeria falls just above the $1,810 income threshold for Gavi support. (The details of the threshold are a bit more complicated than that, as eligibility also depends on years since crossing the threshold, but the gist is: Nigeria is big and just above the bar.) Angola, with the sixth largest number of malaria deaths in the world and a GNI per capita of $2,130 in 2023, is in a similar boat.
Check the Flourish chart at https://flo.uri.sh/visualisation/19934952/embed?auto=1
Dr. Mohammed Pate, Nigeria’s health minister is a former Harvard professor who is widely respected in global health circles and was briefly tapped to lead Gavi. When he took up his role in Nigeria instead, he balked at the price Nigeria was about to pay for malaria vaccines. Plans were scaled back and a negotiation ensued. As it stands, the viability of a big global push on malaria vaccination may hinge on finding a new compromise on co-financing requirements in Nigeria.
Everywhere, everyone, all at once
Right now, the biggest malaria burden countries like Nigeria and DRC have been contemplating a phased rollout, starting in a couple of states or provinces, and focused exclusively on new cohorts of infants. That means most kids in most places, including almost all kids alive today, will never get the vaccine.
Taken at face value, Gavi’s current plan for vaccination rollout implies something like the dark green line in the figure below: a gradual ramp up, reaching full coverage in about 8 to 10 years from now.
Check out the Flourish chart at https://flo.uri.sh/visualisation/18560896/embed?auto=1
The alternative is to frontload the roll-out: all kids, all ages, and start with a bang. Simple demographic arithmetic makes a strong case for that approach. Eventually, vaccinating all infants means vaccinating everybody. But in the short term, there are millions of older kids at risk for malaria who are unvaccinated.
The WHO position paper on malaria vaccines states: “At the time of vaccine introduction, catch-up vaccination can be considered in children up to 5 years of age.” The formal WHO recommendation on the R21 vaccine is for children 5 months and older, with no upper limit.
The gap between the Gavi baseline scenario and this more ambitious plan is not small. Cumulatively, it would mean deploying nearly 600 million additional doses between now and 2033.
Supply is not really a problem. The manufacturing capacity claimed by the Serum Institute, who is producing R21 in India, is not quite as much as the world could hypothetically absorb in the short term, but it’s close.
The main concern – apart from money, of course – is logistics and take-up. Can DRC deliver doses and persuade kids to come back for four shots? And if not, should they go slow and focus on quality over quantity?
In Ghana, Kenya, and Malawi, which participated in the WHO’s large-scale malaria vaccine pilot, coverage for the first dose was 96 percent, falling to 87 percent for the second, 78 percent for the third, and just 39 percent for the fourth. And that last number was mostly due to some administrative limits on how old kids could be for their fourth dose. So clearly it’s possible to deliver these vaccines and get buy-in from communities.
Once again, the question comes back to cost. The WHO pilot got those numbers by spending big on rollout. Replicating the pilot’s success will require mustering similar resources at a larger scale.
Who needs to do what?
It’s not easy to find 2 billion dollars between the sofa cushions. So where is all the extra spending needed to accelerate the malaria vaccine rollout supposed to come from? Here are a few ideas, tailored to specific actors.
Gavi, the Vaccine Alliance:
- Prioritize the cheaper, equally effective R21 over RTS,S. Gavi has taken pains to shield countries from the higher cost of RTS,S. But Gavi’s own budget is finite. The point remains that to maximize lives saved with scarce resources, it is hard to justify spending money on RTS,S rather than R21 in the short term.
- Let Nigeria and Angola back in. As shown above, two of the countries with the largest total malaria burden in the world are currently eligible for limited or no assistance from Gavi. That jeopardizes the world’s ability to make a serious dent in malaria deaths with these new vaccines. Gavi should be prepared to bend the rules.
The Global Fund for AIDS, Tuberculosis, and Malaria:
- Don’t fight the new technology; fund vaccine rollout. Global Fund officials have expressed fear that malaria vaccines are going to crowd out their funding for other malaria control measures. It shouldn’t. But rather than resort to Luddism, the Global Fund needs to get on board with scientific progress. Vaccine procurement is normally Gavi’s job, but vaccine rollout is arguably closer to the traditional role and capabilities of the Global Fund – working with governments and third parties on the ground to actually implement. There’s a huge financing gap on rollout. Global Fund should fund it.
- Relax malaria funding caps for Nigeria and DRC. The Global Fund allocates money for different diseases (HIV, TB, malaria) based on country needs, but with a maximum share of the global pie for any single country. The net effect is to cap Nigeria and DRC, the two countries with the biggest malaria burden in the world. It might be time to rethink those caps.
Bilateral donors:
- Fund Gavi. As the main multilateral vehicle for vaccine funding, Gavi is currently in fundraising mode. The new malaria vaccines strengthen the case for rich-country donors like the US and UK to go big on their Gavi contributions.
- Expand total malaria funding. There is a temptation to reallocate money from other malaria control measures to fund malaria vaccines. But new innovation in the malaria space is pushing out the point of diminishing marginal returns. Technology progress justifies more investment, not less. Donors should avoid a zero-sum situation where they reallocate from the Global Fund’s budget for malaria drugs or bed nets to fund malaria vaccines through Gavi (as the UK is rumored to be contemplating).
- If necessary, reallocate from outside global health. If donors need to reallocate money from other parts of the aid budget, look outside the health verticals like Gavi and Global Fund to some of your lower-impact bilateral programs in middle-income countries. The time is ripe to prioritize lives saved over diplomatic vanity projects in countries that don’t need the money.
Philanthropy:
- Don’t get hung up on the vaccine pipeline. One source of hesitancy in the philanthropic community is whether money is better spent on next generation vaccines in the pipeline. But in any realistic scenario, those are years off from actual use. Right now, the deployment of R21 could save hundreds of thousands of lives at low cost. Those lives aren’t coming back, and there’s little fear of path dependency: countries can switch in five years’ time if a better vaccine comes along.
- Short term, there’s a big opportunity for flexible money with limited risk of fungibility. Philanthropy likes to do new, innovative things that governments can’t do. In the long term, official donors will, hopefully, fully fund malaria vaccines wherever they are needed. But in the short term, they simply can’t. Even if Gavi, Global Fund, and bilateral donors heed our calls above, a huge funding gap will remain over the next five to seven years which philanthropic money is uniquely suited to fill.
Foreign aid and philanthropy can’t do everything. From slow economic growth to civil war, a bit more money can’t cure all ills. But some problems really can be solved with a simple shot.
Humanity has been battling malaria for thousands of years. Even after billions spent on malaria control and constant advances in malaria drugs and insecticide treated nets, the drop in global malaria mortality rates has been roughly canceled out by population growth, leading to almost no decline in total malaria deaths over the last decade. Now we have a new tool. Malaria vaccines offer a real chance to turn the tide on the global malaria epidemic and avert hundreds of thousands of child deaths. But so far, the policy response has been sluggish. Some of that is just inertia, some of it is penny pinching. In any case, for millions of kids, the clock is ticking.
By Ryan Duncombe , Karam Elabd and Justin Sandefur
