Vaccine – 7 May 2015 :: Supplement – Expanding the Evidence Base to Inform Vaccine Introduction: Program Costing and Cost-effectiveness Analyses

Volume 33, Supplement 1, Pages A1-A254 (7 May 2015)

Supplement – Expanding the Evidence Base to Inform Vaccine Introduction: Program Costing and Cost-effectiveness Analyses
pp. A1-A254 (7 May 2015)
Perspectives on expanding the evidence base to inform vaccine introduction: Program costing and cost-effectiveness analyses
Jon Kim Andrusa, Damian G. Walkerb,

Over the past decade, the Pan American Health Organization’s (PAHO) ProVac Initiative has worked with countries to promote the development and use of evidence for immunization policymaking [1]. This supplement features examples of ProVac’s country-led research and other partner efforts in this area with an emphasis on analyses of cost-effectiveness, program costs and financial flows. The findings from these studies represent one important outcome of a broader objective to strengthen and institutionalize national capacity to generate, assess, interpret and use local data in the decision making process. Achieving this broader objective has always been a guiding principle of ProVac’s work [2].

Due to the success of ProVac, PAHO has received numerous requests for similar support from countries outside of the Americas Region. Therefore, in 2011, the ProVac International Working Group was formed with the aim of transferring the ProVac Initiative’s methods and tools to other WHO regions [3]. The International Working Group includes the Agence de Médicine Préventive (AMP), the United States’ Centers for Disease Control and Prevention (CDC), the Program for Appropriate Technologies in Health (PATH), PAHO, the Sabin Vaccine Institute, and World Health Organization headquarters and its regional offices for Africa (AFRO), Eastern Mediterranean (EMRO) and Europe (EURO). A total of 17 countries in these three regions received training from the International Working Group over a two year period resulting in nine cost-effectiveness studies [3].

The impact of ProVac’s mission to increase national capacity to make evidence-based immunization policy is difficult to quantify. However, cost-effectiveness analyses in this supplement demonstrate the quality of evidence a national team can produce for their own decision making use when given access to flexible tools and training. Nine studies were supported through the ProVac IWG platform and results from Albania, Croatia, Egypt, Georgia, Iran, Kenya, Senegal and Uganda are featured in this supplement [4], [5], [6], [7], [8], [9] and [10]. Another six studies featured in this supplement were from countries in the PAHO Region, including Argentina, Belize, Brazil, Honduras, Paraguay and Peru [11], [12], [13], [14], [15] and [16]. They were all led by national health professionals and stakeholders.

These analyses provide an important update to the cost-effectiveness literature on new vaccines from a diverse set of country contexts. With the exception of one cost-effectiveness analysis developed in a high-income country setting (Croatia) with no access to affordable vaccine prices, the findings from the cost-effectiveness research support the previously published evidence that pneumococcal conjugate, rotavirus and HPV vaccines represent good value for money, where disease burden is substantial and/or treatment costs are relatively high and the vaccines can be procured at an affordable price. All primary results from these analyses were subjected to sensitivity analyses to examine the robustness of the findings to changes in the values of key inputs and assumptions. For example, these analyses often considered vaccine price trends over time and other technical or programmatic uncertainties (i.e. booster doses, herd immunity and delivery strategies). Since many countries that received support from the ProVac IWG will graduate from Gavi subsidies in the coming years, these additional analyses were useful to explore the impact of price changes in the cost-effectiveness results. While the results are subject to uncertainty, the conclusions were stable.

The supplement also highlights a recent multi-country study on the costs and financing of routine immunization and new vaccines (EPIC) [17]. The EPIC study included six countries: Benin, Ghana, Honduras, Moldova, Uganda and Zambia. This work represents the first systematic evaluation of costs in countries with a baseline of routine immunization, while also estimating the incremental cost of new vaccines (pneumococcal and rotavirus) to the routine system [18].
The EPIC studies are unique in both the breadth and depth of the data collected from over 300 primary health care facilities across the six countries. An important outcome of this work was the development and use of a Common Approach to costing [17], as well as the creation of a community of practice around cost and financial analysis of immunization. The costing studies allow us to not only describe the range of total and unit costs of routine immunization (RI) [18], [19], [20] and [21], but also to evaluate more systematically the determinants of costs and productivity [22] and [23]. Finally, each country team undertook a financial mapping of the total resources available for routine immunization by source [24] and [25]. This work will be used to improve budgeting and planning of national immunization programs. The evidence will also be used to inform advocacy aimed at greater domestic resource mobilization.

Finally, leading researchers, decision makers and donors comment on the development and use of the data featured in this supplement from their perspective. The four commentaries highlight the following themes (1) the potential role of cost-effectiveness analysis in price negotiation; (2) the continued need for models and methodological approaches that can be adapted for use in low resource policy settings; and (3) the juxtaposition of supporting country-level decision making in the context of donor priority setting [26], [27], [28] and [29]. From Thailand’s Health Intervention and Technology Assessment Program’s (HITAP) perspective, cost-effectiveness data is critical in price negotiation for countries, like Thailand, that do not have access to donor subsidies or innovative financing mechanisms [26]. We see how the HITAP approach could easily be adapted in a context like Croatia, where PCV was found to be not cost-effective at the current assumed price of US$30-35 [8]. Decision support systems as a fundamental underpinning to making better choices with public monies are described from a decision scientist’s perspective in ‘The ProVac Initiative and evolving decision’support’ [27]. As we’ve seen with the implementation of ProVac, these systems require a long-term investment and commitment to building institutions that require and support an evidence-based approach.

We have only just begun with immunization programs but the lessons from the ProVac Initiative may serve to guide future work in promoting health technology assessment across the health sector. Lastly, Gavi and the immunization program manager from Honduras, a Gavi-graduating country, share perspectives on the increasing importance of priority-setting at country level for effective immunization policy and the support that Gavi-eligible countries may need today in order to enter into the near-term graduation from Gavi support [28] and [29]. All commentaries combined offer an insight into developing a forward thinking approach to the use of evidence for immunization decision making.

We hope the reader finds that this collection of articles provides useful insight into the work required to help countries strengthen their capacity to make evidence-based policy decisions. Accelerating national policy development on new vaccines adoption, together with rapid deployment of vaccines when appropriate, will contribute to saving more lives more quickly.

The studies published herein include but are not limited to work conducted by the Pan American Health Organization’s ProVac Initiative, the ProVac International Working Group and the EPIC study with financial support from the Bill and Melinda Gates Foundation (grant no. OPP50788). The views expressed in each article are those of the authors alone and do not necessarily reflect the official policy or position of the Bill and Melinda Gates Foundation or the Pan American Health Organization.