New vaccine adoption: qualitative study of national decision-making processes in seven low- and middle-income countries

Abstract

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.

Are Current Cost-Effectiveness Thresholds for Low- and Middle-Income Countries Useful? Examples from the World of Vaccines

“…Second, LMICs may not consider costeffectiveness results, because they lack the expertise to interpret them. Third, other criteria are more important than cost effectiveness for such decisions, as suggested by qualitative research on this topic [20]. For instance, while most of the analyses reviewed for both HPV and rotavirus make reference to the 'WHO-CHOICE thresholds' in helping to interpret the results of the cost-effectiveness analysis [10,11], they often make clear that budgetary constraints are a primary consideration in determining whether a 'cost-effective' intervention is implemented.…”

“…In eligible countries, the price paid for the vaccine in the initial years of vaccine introduction is heavily subsided by the GAVI Alliance, with the cost of the programmes being transitioned to the countries themselves in later years. It has been suggested that the availability of this external support can be a major driver in vaccine adoption decisions [20]. Furthermore, the choice of payer (whether the GAVI Alliance, the national government or individual households) can substantially affect key outcomes of vaccine evaluations, including vaccine costs (whether GAVI-negotiated prices, country co-payment levels or market prices) and benefits (which depend on which budget they accrue to and what outcomes are valued by the payer).…”

Challenges to sustainable immunization systems in Gavi transitioning countries

“…Finally, two papers specifically focused on national decision-making processes provide a review of available information from country case studies (15 countries) [19] or country interviews (95 countries) [20] to understand factors affecting decision-making on new vaccine adoption in low- and middle-income countries. These papers conclude that the local burden of disease data, vaccine prices and the cost implications of adopting a new vaccine are of particular importance in new vaccine adoption decisions in lower-middle-income countries (LMICs) and that the underlying driver for vaccine adoption decisions in Gavi-eligible countries was the desire to seize windows of opportunity for Gavi funding [19], [20].…”

Reflections on the development of health economics in low- and middle-income countries

“…A recent study of decision-making processes in relation to vaccines suggests that governments in low-and middle-income countries so far pay much less attention to cost-effectiveness evidence, with funding availability and political factors dominating decision-making [18].…”