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.

Impact of measles elimination activities on immunization services and health systems: findings from six countries.

BACKGROUND: One of the key concerns in determining the appropriateness of establishing a measles eradication goal is its potential impact on routine immunization services and the overall health system. The objective of this study was to evaluate the impact of accelerated measles elimination activities (AMEAs) on immunization services and health systems in 6 countries: Bangladesh, Brazil, Cameroon, Ethiopia, Tajikistan, and Vietnam. METHODS: Primary data were collected from key informant interviews and staff profiling surveys. Secondary data were collected from policy documents, studies, and reports. Data analysis used qualitative approaches. RESULTS: This study found that the impact of AMEAs varied, with positive and negative implications in specific immunization and health system functions. On balance, the impacts on immunization services were largely positive in Bangladesh, Brazil, Tajikistan, and Vietnam, while negative impacts were more significant in Cameroon and Ethiopia. CONCLUSIONS: We conclude that while weaker health systems may not be able to benefit sufficiently from AMEAs, in more developed health systems, disruptions to health service delivery are unlikely to occur. Opportunities to strengthen the routine immunization service and health system should be actively sought to address system bottlenecks in order to incur benefits to eradication program itself as well as other health priorities.

Socioeconomic and cultural implications of health interventions: the case of smoking in Ethiopia.

PIP: The growth rate of tobacco production and of cigarette smoking is rapidly increasing in developing countries. This article examines smoking as a health problem in Ethiopia. According to the author, Ethiopia is in a favorable position for action in this area because smoking is not yet extensive (restricted largely to urban areas) and the Government is committed to preventing a smoking epidemic. However, tobacco plays an important and growing role in Ethiopia's economy. Commercial production tobacco, which is a state monopoly, accounted for 5% of the total industrial gross value of production in 1977 and over 1% of the total number of employees in industry. Of total government revenues in 1977, 1.6% was from tobacco. Household expenditure on tobacco was 1.5-2.9% in 1975, compared with 1.8-3% for medical care. The smoking habit is extensively promoted through advertising. Given the general problems of poverty and unemployment in Ethiopia, it seems unreasonable to press for changes that would entail a loss of government revenues and create unemployment. An alternative solution to this problem is to stimulate self-reliance in the environment of the working people. Smoking must be made into a politicl issue at both the national and international level. On the national level, health workers would have to continue spreading knowledge on the harmful effects of smoking, study and disseminate better ways to prevent smoking, and lobby for better legislation on the issue. The international level is particularly significant, not only because tobacco interests are transnational, but because the success of an antismoking campaign is related to the struggle for a New Economic order. Such an approach could provide the economic basic for effective action to reduce tobacco production and consumption.^ieng