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

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.

Cost-effectiveness of malaria diagnostic methods in sub-Saharan Africa in an era of combination therapy.

OBJECTIVE: To evaluate the relative cost-effectiveness in different sub-Saharan African settings of presumptive treatment, field-standard microscopy and rapid diagnostic tests (RDTs) to diagnose malaria. METHODS: We used a decision tree model and probabilistic sensitivity analysis applied to outpatients presenting at rural health facilities with suspected malaria. Costs and effects encompassed those for both patients positive on RDT (assuming artemisinin-based combination therapy) and febrile patients negative on RDT (assuming antibiotic treatment). Interventions were defined as cost-effective if they were less costly and more effective or had an incremental cost per disability-adjusted life year averted of less than US$ 150. Data were drawn from published and unpublished sources, supplemented with expert opinion. FINDINGS: RDTs were cost-effective compared with presumptive treatment up to high prevalences of Plasmodium falciparum parasitaemia. Decision-makers can be at least 50% confident of this result below 81% malaria prevalence, and 95% confident below 62% prevalence, a level seldom exceeded in practice. RDTs were more than 50% likely to be cost-saving below 58% prevalence. Relative to microscopy, RDTs were more than 85% likely to be cost-effective across all prevalence levels, reflecting their expected better accuracy under real-life conditions. Results were robust to extensive sensitivity analysis. The cost-effectiveness of RDTs mainly reflected improved treatment and health outcomes for non-malarial febrile illness, plus savings in antimalarial drug costs. Results were dependent on the assumption that prescribers used test results to guide treatment decisions. CONCLUSION: RDTs have the potential to be cost-effective in most parts of sub-Saharan Africa. Appropriate management of malaria and non-malarial febrile illnesses is required to reap the full benefits of these tests.

The distribution of health planning and management responsibilities between centre and periphery: historical patterns and reform trends in four Caribbean territories.

The degree to which health planning and management functions are decentralised has been one of the key questions in developing countries from when they first gained independence. This paper's aim is to examine the question of the historical distribution of responsibilities within the health sector of four territories, Trinidad and Tobago, the Bahamas, Martinique, and Suriname, in order to identify the roles of the different levels, changes over time and recent reform trends, and to seek to explain the reasons for changes. These territories were selected deliberately, on the grounds of their different colonial backgrounds. Common features included identification over several decades of management structures and skills as key problems; proposals for regionalisation and greater hospital autonomy as desirable solutions; and in three of the four territories, recent implementation of major structural reforms. Important influences on the timing and nature of decentralisation reforms included political and economic factors, the attitudes of the public service unions and the medical profession, and external funders who were particularly important in financing reforms and supporting the development of detailed implementation plans. The bureaucratic inheritance of the two English-speaking countries provided major barriers to structural change, which they have addressed through reforms involving the creation of agencies with delegated authority.

Financing of health care in four Caribbean territories: a comparison with reforms in Europe.

This paper considers health care finance in four Caribbean territories and plans for reform in comparison with developments in European countries, to which these territories are historically linked. European health care reforms are aimed at making resource allocation in health care more efficient and more responsive to consumers' demands and preferences. These reforms in Europe have been continuing without appearing to have influenced the developments in the Caribbean very much, except in Martinique. In Trinidad and Tobago current reform entails delegation of responsibility for providing services to four regional health authorities and no purchaser/provider split at the regional or facility level as in the UK has been implemented. In the Bahamas, managed care arrangements are likely to emerge given the proximity of the United States. Recent universal coverage reform in Martinique was aimed at harmonisation of finance by bringing social security and social aid functions together under one management structure and may provide more opportunities for contracting and other initiatives towards greater efficiency. The first priority in Suriname is to restore proper functioning of the current system. Reforms in the four Caribbean territories have a largely administrative character and affect the organisation of the third party role in health care rather than fundamentally changing the relationship between this third party and the various other parties in health care.

St. Vincent and the Grenadines.

Saint Vincent and the Grenadines conjures up images of a yachting haven and a quiet tourists' paradise. The conflicting demands of a growing population, a middle-income economy dominated by fishing, plantation agriculture and tourism, and environmental and social concerns, all contribute to marine stress on the limited, precious, but internationally important resources. While the vision exists to manage effectively coastal and offshore resources, the institutional, financial and social capital to achieve that vision is limited. Development of the fledgling partnerships between local communities, national governmental structures and the international research, government and donor organisations seems the best hope to conserve the environment and coastal livelihoods of the islands.