Health Policy and Planning
Supplement: Policy making for new vaccines in low- and middle-income countries
Volume 27 suppl 2 May 2012
Guest Editors: Sandra Mounier-Jack and Helen Burchett
Pauline Paterson and Heidi J Larson
The role of publics in the introduction of new vaccines
Health Policy Plan. (2012) 27(suppl 2): ii77-ii79 doi:10.1093/heapol/czs038
- The ‘public’ in public engagement could be a variety of stakeholders.
- Engaging with the public builds trust and helps to identify concerns that need to be addressed.
- There is a need for more research on the impact of different public engagement strategies on vaccination programmes to improve their effectiveness.
- The importance of listening to and engaging publics in the design and implementation of immunization policies and programmes has been well established (Waisbord 2004; Cooper et al. 2008; Obregon 2009; Larson et al. 2010; Larson et al. 2011). There are a number of examples of the costs (financial and social) of not involving publics early, the most acute being the boycott of polio vaccination in five states in Northern Nigeria in 2003 (Yahya 2007).
- Several papers in this special issue highlight potential roles of publics in the introduction of new vaccines, mostly at the level of implementation, but some point to the importance of bringing the role of citizen voices earlier into the decision-making process—i.e. not just as players to implement decisions made by central authorities, but to be a part of decision-making processes (Wonodi et al. 2012).
- The ‘public’ in public engagement could be a variety of stakeholders; such as individuals, parents, policy-makers (Mantel and Wang 2012), researchers and clinicians (Burchett et al. 2012), immunization programme managers (Brooks and Ba-Nguz 2012; Gordon et al. 2012), ‘global/regional bodies’ (Makinen et al. 2012), advocacy groups, or influential individuals (Makinen et al. 2012), such as religious leaders (Wonodi et al. 2012). …
Carsten Mantel and Susan A Wang
The privilege and responsibility of having choices: decision-making for new vaccines in developing countries
Health Policy Plan. (2012) 27(suppl 2): ii1-ii4 doi:10.1093/heapol/czs041
Decisions to introduce new vaccines into national immunization programmes have become a highly complex endeavour. When the Expanded Programme on Immunization (EPI) was established in 1974 through a World Health Assembly resolution to build on the success of the global smallpox eradication programme and to ensure that all children in all countries benefit from life-saving vaccines, the first six diseases targeted by EPI were diphtheria, pertussis, tetanus, polio, measles and tuberculosis (WHO 1974). Today, thanks to scientific advancements and renewed global interest in immunization, more than a dozen1 antigens have been made available through public health services in developing countries, with increasingly reduced time delay compared with introduction in industrialized countries. Country decision-makers can select vaccines from a portfolio of options. This is a privilege and a serious responsibility requiring due consideration, as any decision to select one vaccine will need to be taken in light of the opportunity costs of not investing in another vaccine or another (health) intervention. Moreover, country decision-makers do not form their decisions in a vacuum; the number of immunization stakeholders in both the public and the private sectors has vastly increased and those stakeholders are equipped with varying levels of knowledge and expertise and may have vested interests.
The multitude of factors influencing country decisions to introduce new vaccines, and the process for making these decisions is becoming increasingly important. These factors and processes are briefly outlined and discussed below.
Sources of information and the decision-making process
One of the main and undisputed sources of information for decision making on new vaccine introduction in developing countries is the World Health Organization (WHO) global recommendations and policy guidelines, such as the vaccine position papers. These position papers are based on a thorough and graded review of available evidence by an independent Strategic Advisory Group of Experts in immunization (SAGE) and they
H E D Burchett, S Mounier-Jack, U K Griffiths, R Biellik, P Ongolo-Zogo, E Chavez, H Sarma, J Uddin, M Konate, Y Kitaw, M Molla, S Wakasiaka, L Gilson, and A Mills
New vaccine adoption: qualitative study of national decision-making processes in seven low- and middle-income countries
Health Policy Plan. (2012) 27(suppl 2): ii5-ii16 doi:10.1093/heapol/czs035
W Scott Gordon, Andrew Jones, and John Wecker
As more new and improved vaccines become available, decisions on which to adopt into routine programmes become more frequent and complex. This qualitative study aimed to explore processes of national decision-making around new vaccine adoption and to understand the factors affecting these decisions.
Ninety-five key informant interviews were conducted in seven low- and middle-income countries: Bangladesh, Cameroon, Ethiopia, Guatemala, Kenya, Mali and South Africa. Framework analysis was used to explore issues both within and between countries.
The underlying driver for adoption decisions in GAVI-eligible countries was the desire to seize GAVI windows of opportunity for funding. By contrast, in South Africa and Guatemala, non-GAVI-eligible countries, the decision-making process was more rooted in internal and political dynamics.
Decisions to adopt new vaccines are, by nature, political. The main drivers influencing decisions were the availability of funding, political prioritization of vaccination or the vaccine-preventable disease and the burden of disease. Other factors, such as financial sustainability and feasibility of introduction, were not as influential. Although GAVI procedures have established more formality in decision-making, they did not always result in consideration of all relevant factors. As familiarity with GAVI procedures increased, questioning by decision-makers about whether a country should apply for funding appeared to have diminished.
This is one of the first studies to empirically investigate national processes of new vaccine adoption decision-making using rigorous methods. Our findings show that previous decision-making frameworks (developed to guide or study national decision-making) bore little resemblance to real-life decisions, which were dominated by domestic politics. Understanding the realities of vaccine policy decision-making is critical for developing strategies to encourage improved evidence-informed decision-making about new vaccine adoptions. The potential for international initiatives to encourage evidence-informed decision-making should be realised, not assumed.
Introducing multiple vaccines in low- and lower-middle-income countries: issues, opportunities and challenges
Health Policy Plan. (2012) 27(suppl 2): ii17-ii26 doi:10.1093/heapol/czs040
C B Wonodi, L Privor-Dumm, M Aina, A M Pate, R Reis, P Gadhoke, and O S Levine
Using social network analysis to examine the decision-making process on new vaccine introduction in Nigeria
Health Policy Plan. (2012) 27(suppl 2): ii27-ii38 doi:10.1093/heapol/czs037
Marty Makinen, Miloud Kaddar, Vivikka Molldrem, and Lara Wilson
Objectives Lower-middle-income countries (LMICs) are lagging behind both high-income and low-income countries in new vaccine adoption. Our study involved the following objectives: (1) understand the decision-making processes of LMICs on new vaccine adoption, (2) identify the factors influencing LMIC decisions, (3) obtain the views of vaccine manufacturers about LMIC markets for new vaccines, and (4) make recommendations concerning how to speed up and improve decision making, including proposing mechanisms for implementation of the recommendations.
Methods Collect and analyse qualitative data from participants in decision making in 15 case study countries [12 LMICs and three upper-middle-income countries (UMICs)] and multinational and developing country vaccine manufacturers.
Findings Interviews of actors in decision making indicate that the aspects deemed most important for adoption are: World Health Organization (WHO) recommendations, the existence of local epidemiological data and a set of factors comprising affordability, cost-effectiveness and overall cost of the new vaccine for the programme. National Immunization Technical Advisory Groups (NITAG) have a key role in advising decision-makers, although their resources and capacity vary. Country decision-makers and manufacturers both see advantages in pooled procurement mechanisms for vaccine purchasing. Recommendations for countries and the international community involve assisting with making epidemiological data and vaccine market information accessible to countries, building and reinforcing related analysis capacity, and assisting with purchasing mechanisms and practices such as pooled procurement.
New vaccine adoption in lower-middle-income countries
Health Policy Plan. (2012) 27(suppl 2): ii39-ii49 doi:10.1093/heapol/czs036
Alan Brooks and Antoinette Ba-Nguz
Country planning for health interventions under development: lessons from the malaria vaccine decision-making framework and implications for other new interventions
Health Policy Plan. (2012) 27(suppl 2): ii50-ii61 doi:10.1093/heapol/czs039
H E D Burchett, S Mounier-Jack, U K Griffiths, and A J Mills
National decision-making on adopting new vaccines: a systematic review
Health Policy Plan. (2012) 27(suppl 2): ii62-ii76 doi:10.1093/heapol/czr049
In recent years numerous new vaccines have been developed, offering potential reductions in the morbidity and mortality caused by a range of diseases. This has led to increased interest in decision-making about the adoption of new vaccines into national immunization programmes. This paper aims to systematically review the literature on national decision-making around the adoption of new vaccines.
A thematic framework was developed inductively through analysis of the vaccine adoption decision-making frameworks included in the review. This thematic framework was then applied to the remaining studies included in the review.
In total, 85 articles were included in the review: 39 articles describing examples of vaccine adoption decision-making, 26 presenting vaccine decision-making frameworks, 21 empirical articles of decision-making relating to vaccine adoption and 19 theoretical essays.
An analysis of vaccine adoption decision-making frameworks identified nine broad categories of criteria: the importance of the health problem; vaccine characteristics; immunization programme considerations; acceptability; accessibility, equity and ethics; financial/economic issues; impact; alternative interventions and the decision-making process.
The quality of the empirical studies was varied. Although some of the issues included in the frameworks were similar to those considered in the studies, there were also some notable differences. On the whole, the frameworks were more comprehensive than the studies, including a greater range of criteria.
The existing literature provides a good foundation for further research into vaccine adoption decision-making. The current review, in pulling together what is already known and by identifying strengths, weaknesses and gaps in the existing evidence base, aims to encourage a more focused and rigorous approach to the topic in future. This could help to identify the most appropriate ways to develop vaccine adoption decision-making, so as to improve decisions and, ultimately, health outcomes