Constraints to Vaccine Adoption in Lower and Middle Income Countries

Results for Development Institute (R4D) completed a study funded by the Bill & Melinda Gates Foundation on the challenges that Lower Middle Income Countries (LMICs) face as they consider the adoption of new vaccines. The study was conceived in response to a growing recognition on the part of the WHO that LMICs receive little support for their vaccination programs, despite having a heavy burden of disease and accounting for a large share of the world’s poor.

Some questions the study addressed are: What are the barriers/challenges that limit the rate of new vaccine adoption by LMICs? What are the potential options to address these rate limiting constraints? And what are the likely costs, benefits and implications of various options for supporting countries to address identified rate limiting constraints?

Based upon its analyses the study developed prioritized recommendations at the global, regional and country level under the themes of: (1) evidence and capacity building, (2) financing, (3) policy and advocacy, and (4) supply and procurement.

Substantial benefits could be attained by enhancing new vaccine introduction in LMICs, including: contributing to achieving the Millennium Development Goals; improvements in global health by preventing priority diseases; paving the way for other countries to introduce new vaccines; and providing potentially large and attractive markets for manufacturers.

LMICs' rates of vaccine adoption will influence vaccine supply, pricing, and demand forecasting, and thus could encourage a broader market strategy for manufacturers.

This study gathered data on vaccine introduction from a variety of sources, including visits to conduct in-depth assessments in nine LMICs and telephone and email interviews with key actors in new vaccine decision making in six more, and conducting interviews with global leaders in all aspects of vaccine introduction, supply, and financing. These interviews and quantitative analyses performed by the study informed recommendations on how to overcome the barriers to introducing the new and underutilized vaccines in LMICs.

In November 2010, WHO’s Strategic Advisory Group of Experts (SAGE) offered an unsolicited endorsement of the study's key recommendations. In particular, the SAGE encouraged the WHO to allocate more resources to support LMICs. This endorsement, as well as the study’s finding that price and pricing are one of the top factors influencing vaccine decision-making, have led to meetings and work by the WHO on issues of vaccine prices and price transparency.

The study team now is disseminating the report at the global, regional, and country level, as well as with vaccine manufacturers. Presentations on the report were made at the 3rd International Conference on Health Financing in Developing and Emerging Countries, Centre d’Etudes et de Recherches sur le Développement International, Université d’Auvergne, Clermont-Ferrand, France in May 2011 and at the New and Under-used Vaccine Implementation Meeting, Montreux, Switzerland in June 2011.

The R4D team that conducted the work was led by Study Director Marty Makinen, and included consultant Piers Whitehead and R4D staff members Robert Hecht, Lara Wilson, Maria Belenky, Amrita Palriwala, and Kira Thorien. The study team benefitted from input provided by an Advisory Group co-chaired by Violaine Mitchell (Bill & Melinda Gates Foundation) and Miloud Kaddar (World Health Organization) with representatives from WHO regional offices, GAVI, UNICEF, vaccine manufacturers and other experts. The advisory group provided critical feedback on all aspects of the study, including the development and implementation of the work plan, and recommendations resulting from the project. The study began in October 2009 and was completed in March 2011.

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