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

Impact and Cost-Effectiveness of Alternative Human Papillomavirus Vaccines for Preadolescent Girls in Mozambique: A Modelling Study

Mozambique has one of the highest rates of cervical cancer in the world. Human papillomavirus (HPV) vaccination was introduced in 2021. This study evaluated the health and economic impact of the current HPV vaccine (GARDASIL^® hereafter referred to as GARDASIL-4) and two other vaccines (CECOLIN^® and CERVARIX^®) that could be used in the future. A static cohort model was used to estimate the costs and benefits of vaccinating girls in Mozambique over the period 2022-2031. The primary outcome measure was the incremental cost per disability-adjusted life-year averted from a government perspective. We conducted deterministic and probabilistic sensitivity analyses. Without cross-protection, all three vaccines averted approximately 54% cervical cancer cases and deaths. With cross-protection, CERVARIX averted 70% of cases and deaths. Without Gavi support, the discounted vaccine program costs ranged from 60 million to 81 million USD. Vaccine program costs were approximately 37 million USD for all vaccines with Gavi support. Without cross-protection, CECOLIN was dominant, being cost-effective with or without Gavi support. With cross-protection and Gavi support, CERVARIX was dominant and cost-saving. With cross-protection and no Gavi support, CECOLIN had the most favorable cost-effectiveness ratio. Conclusions: At a willingness-to-pay (WTP) threshold set at 35% of Gross Domestic Product (GDP) per capita, HPV vaccination is cost-effective in Mozambique. The optimal vaccine choice depends on cross-protection assumptions.

Immunoinformatics-guided design of a multi-valent vaccine against Rotavirus and Norovirus (ChRNV22)

Rotavirus (RV) and Norovirus (NV) are the main viral etiologic agents of acute gastroenteritis (AG), a serious pediatric condition associated with significant death rates and long-term complications. Anti-RV vaccination has been proved efficient in the reduction of severe AG worldwide, however, the available vaccines are all attenuated and have suboptimal efficiencies in developing countries, where AG leads to substantial disease burden. On the other hand, no NV vaccine has been licensed so far. Therefore, we used immunoinformatics tools to develop a multi-epitope vaccine (ChRNV22) to prevent severe AG by RV and NV. Epitopes were predicted against 17 prevalent genotypes of four structural proteins (NV's VP1, RV's VP4, VP6 and VP7), and then assembled in a chimeric protein, with two small adjuvant sequences (tetanus toxin P2 epitope and a conserved sequence of RV's enterotoxin, NSP4). Simulations of the immune response and interactions with immune receptors indicated the immunogenic properties of ChRNV22, including a Th1-biased response. In silico search for putative host-homologous, allergenic and toxic regions also indicated the vaccine safety. In summary, we developed a multi-epitope vaccine against different NV and RV genotypes that seems promising for the prevention of severe AG, which will be further assessed by in vivo tests.

Key decision-making factors for human papillomavirus (HPV) vaccine program introduction in low-and-middle-income-countries: Global and national stakeholder perspectives

Low-and-middle-income countries (LMICs) experience a high burden of cervical cancer. The human papillomavirus (HPV) vaccine prevents high-risk strains of HPV that cause cervical cancer; however, the integration of HPV vaccines into national immunization programs within many LMICs has been suboptimal. Our study evaluated key factors that drive the decision-making process for the implementation of HPV vaccine programs in LMICs. Stakeholder analysis and semi-structured in-depth interviews were conducted with national and global stakeholders. Interview data were analyzed through qualitative descriptive methods. Findings from our study revealed the decision-making process for HPV vaccines requires the involvement of multiple institutions and stakeholders from national and global levels, with decision-making being a country-specific process. Partner considerations, locally driven processes, availability of data, and infrastructure and resource considerations were found to be critical factors in the decision-making process. Future programs should evaluate the best approaches for investing in initiatives to enhance coordination, ensure vaccine introduction is locally driven, increase the availability of data needed for decision-making, and equip countries with the necessary resources to guide country decision-making in the face of increasingly complex decision-making environments.

Business or Hope? The Vaccine of the Day after, a Life Expectancy

This approach reflects the moments when humanity was infected by the new pandemic from a health point of view. The acceleration to find the vaccine that will protect us from the pandemic brings some interesting questions from the point of view of possible side effects and from the point of view of the economy. The growing interest in first producing the so-called ‘morning after’ vaccine calls into question whether this is a purely scientific act open to all countries of the world free of charge. Along the way, there are still the interests of many companies that have been favoured in one way or another to increase their profits. The analysis exposes the paradigm of health versus economy, of life expectancy versus business. Within this framework, humanity is discussed as a balance, perhaps taken advantage of by some of the biotechnology and pharmaceutical companies located in the strongest countries in the market, to the detriment of the weakest.

Partnerships in the introduction of new routine vaccines in Bangladesh: evidence from a prospective process evaluation

OBJECTIVE

To assess the contribution of partners in the introduction of two new vaccines concurrently: pneumococcal 10-valent conjugate vaccine (PCV-10) and inactivated polio vaccine (IPV) into the routine Expanded Programme on Immunization (EPI) in Bangladesh.

DESIGN

We conducted a prospective process evaluation that included the theory of change development, root cause analysis and in-depth investigation. As part of process tracking, we reviewed relevant documents, observed trainers' and vaccinators' training and key stakeholder meetings. We analysed the data thematically.

SETTING

We purposively selected eight Upazila (subdistrict) and one city corporation covering nine districts and seven administrative divisions of Bangladesh.

PARTICIPANTS

Nineteen national key informants were interviewed and 16 frontline health workers were invited to the group discussions considering their involvement in the vaccine introduction process.

RESULTS

The EPI experienced several challenges during the joint introduction of PCV-10 and IPV, such as frequent changes in the vaccine introduction schedule, delays in budget allocation, vaccine supply shortage and higher wastage rates of IPV. EPI addressed these challenges in collaboration with its partners, that is, the World Health Organization (WHO) and United Nations Children's Fund (UNICEF), who provided technical assistance to develop a training curriculum and communication materials and enhanced demand generation at the community level. In addition, the WHO conducted a country readiness assessment for PCV-10, and UNICEF supported vaccine shipment. Other government ministries, City Corporations and municipalities also supported the EPI.

CONCLUSIONS

The partnership among the EPI stakeholders effectively addressed various operational challenges during the joint introduction of PCV-10 and IPV helped strengthen Bangladesh's immunisation systems. These accomplishments are attributed to several factors that should be supported and strengthened for future vaccine introductions in Bangladesh and other low and-middle countries.

Health actor approaches to financing universal coverage strategies for pneumococcal and rotavirus immunisation programmes in low-income and middle-income countries: a scoping review protocol

INTRODUCTION

Sustainable financing of immunisation programmes is an important step towards universal coverage of life-saving vaccines. Yet, financing mechanisms for health programmes could have consequences on the design of universal approaches to immunisation coverage. Effective implementation of immunisation interventions necessitates investigating the roles of institutions and power on interventions. This review aims to understand how sustainable financing and equitable immunisation are conceptualised by health actors like Gavi, and government-related entities across low-income and middle-income countries (LMICs) and how financing mechanisms can affect universal coverage of vaccines.

METHODS AND ANALYSIS

This study protocol outline a scoping review of the peer-reviewed and the grey literature, using established methodological framework for scoping review. Literature will be identified through a comprehensive search of multiple databases and grey literature. All peer-reviewed implementation research studies from the year 2002 addressing financing and universal coverage of immunisation programmes for the pneumococcal conjugated vaccine and rotavirus vaccines immunisation interventions will be included and grey literature published in/after the year 2015. For the study scope, population, concept and context are defined: Population as international and national health stakeholders financing immunisation programmes; Concept as implementation research on pneumococcal conjugate and rotavirus vaccination interventions; and Context as LMICs. Findings will be quantitatively summarised to provide an overview and narratively synthesised and analysed. Studies that do not use implementation research approaches, frameworks or models will be excluded.

ETHICS AND DISSEMINATION

Ethics approval is not required for this scoping review. Findings and recommendations will be presented to implementation researchers and health stakeholders.

Health technology assessment in sub-Saharan Africa: a descriptive analysis and narrative synthesis

Background

Countries in Sub-Saharan Africa (SSA) are moving towards universal health coverage. The process of Health Technology Assessment (HTA) can support decisions relating to benefit package design and service coverage. HTA involves institutional cooperation with agreed methods and procedural standards. We systematically reviewed the literature on policies and capacity building to support HTA institutionalisation in SSA.

Methods

We systematically reviewed the literature by searching major databases (PubMed, Embase, etc.) until June 2019 using terms considering three aspects: HTA; health policy, decision making; and SSA. We quantitatively extracted and descriptively analysed content and conducted a narrative synthesis eliciting themes from the selected literature, which varied in study type and apporach.

Results

Half of the 49 papers identified were primary research studies and mostly qualitative. Five countries were represented in six of ten studies; South Africa, Ghana, Uganda, Cameroon, and Ethiopia. Half of first authors were from SSA. Most informants were policy makers. Five themes emerged: (1) use of HTA; (2) decision-making in HTA; (3) values and criteria for setting priority areas in HTA; (4) involving stakeholders in HTA; and (5) specific examples of progress in HTA in SSA. The first one was the main theme where there was little use of evidence and research in making policy. The awareness of HTA and economic evaluation was low, with inadequate expertise and a lack of local data and tools.

Conclusions

Despite growing interest in HTA in SSA countries, awareness remains low and HTA-related activities are uncoordinated and often disconnected from policy. Further training and skills development are needed, firmly linked to a strategy focusing on strengthening within-country partnerships, particularly among researchers and policy makers. The international community has an important role here by supporting policy- relevant technical assistance, highlighting that sustainable financing demands evidence-based processes for effective resource allocation, and catalysing knowledge-sharing opportunities among countries facing similar challenges.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-021-00293-5.

SMART Vaccines 2.0 decision-support platform: a tool to facilitate and promote priority setting for sustainable vaccination in resource-limited settings

In resource-constrained environments, priority setting is critical to making sustainable decisions for introducing new and underused vaccines and choosing among vaccine products. Donor organisations and national governments in low-income and middle-income countries (LMICs) recognise the need to support prioritisation of vaccine decisions driven by local health system capacity, epidemiology and financial sustainability.

Successful efforts have supported the establishment of National Immunisation Technical Advisory Groups (NITAGs) to undertake evidence-informed decision making (EIDM) in LMICs. Now, attention is increasingly focused on supporting their function to leverage local expertise and priorities. EIDM and priority-setting functions are complex and dynamic processes. Here, we report a pilot of a web-based decision-support tool. Applying tenets of multicriteria decision analysis, SMART Vaccines 2.0 supported transparent, reproducible and evidence-informed priority setting with an easy-to-use interface and shareable outputs.

The pilot was run by the Uganda NITAG who were requested by the Ministry of Health (MOH) in 2016 to produce recommendations on the prioritised introduction of five new vaccines. The tool was acceptable to the NITAG and supported their recommendations to the MOH. The tool highlighted sensitivity in the prioritisation process to the inherent biases of different stakeholders. This feature also enabled examination of the implications of data uncertainty. Feedback from users identified areas where the tool could more explicitly support evidence-to-recommendation frameworks, ultimately informing the next generation of the platform, PriorityVax.

Country ownership and priority setting in vaccine decisions are central to sustainability. PriorityVax promotes auditable and rigorous deliberations; enables and captures the decision matrix of users; and generates shareable documentation of the process.

National decision-making for the introduction of new vaccines: A systematic review, 2010-2020

BACKGROUND

Competing priorities make using a transparent and evidence-based approach important when deciding to recommend new vaccines. We conducted a literature review to document the processes and frameworks for national decision-making on new vaccine introductions and explored which key features have evolved since 2010.

METHODS

We searched literature published on policymaking related to vaccine introduction from March 2010 to August 2020 in six databases. We screened articles for eligibility with the following exclusion criteria: non-human or hypothetical vaccines, the sole focus on economic evaluation or decision to adopt rather than policy decision-making. We employed nine broad categories of criteria from the 2012 review for categorization and abstracted data on the country, income level, vaccine, and other relevant criteria.

RESULTS

Of the 3808 unique references screened, 116 met eligibility criteria and were classified as: a) framework of vaccine adoption decision-making (27), b) studies that analyse empirical data on or examples of vaccine adoption decision-making (45), c) theoretical and empirical articles that provide insights into the vaccine policymaking process (44 + 17 already included in the previous categories). Commonly reported criteria for decision-making were the burden of disease; vaccine efficacy/effectiveness, safety; impact on health and non-health outcomes; economic evaluation and cost-effectiveness of alternative interventions. Programmatic and acceptability aspects were not as often considered. Most (50; 82%) of the 61 articles describing the process of vaccine introduction policymaking highlighted the role of country, regional, or global evidence-informed recommendations and a robust national governance as enabling factors for vaccine adoption.

CONCLUSIONS

The literature on vaccine adoption decision-making has expanded since 2010. We found that policymakers and expert advisory committee members (e.g., National Immunization Technical Advisory Group [NITAG]) increasingly value the interventions based on economic evaluations. The results of this review could guide discussions on evidence-informed immunization decision-making among country, sub-regional, and regional stakeholders.

Lessons Learned from Strategies for Promotion of Evidence-to-Policy Process in Health Interventions in the ECOWAS Region: A Rapid Review

Context:

The West African Health Organization (WAHO) is vigorously supporting evidence-informed policymaking (EIPM) in the countries of West Africa. EIPM is increasingly recognized as one of the key strategies that can contribute to health systems strengthening and the improvement of health outcomes. The purpose of this rapid review is to examine two key examples of evidence-based strategies used to successfully implement health interventions in each of the West African countries and to highlight the lessons learned.

Methods:

A rapid review technique, defined as a type of knowledge synthesis in which systematic review processes are accelerated and methods are streamlined to complete the review more quickly, was used. A PubMed search was conducted using the combination of the following keywords: Health, policy making, evidence, plus name of each of the 15 countries to identify studies that described the process of use of evidence in policymaking in health interventions. Two examples of the publications that fulfilled the study inclusion criteria were selected.

Results:

Among the key processes used by the countries to promote EIPM in health interventions include policy cycle mechanism and political prioritization, rapid response services, technical advisory group and steering committees (SCs), policy dialog, capacity-strengthening mechanisms, local context evidence and operational guidelines, multisectoral action and consultative process.

Conclusion:

Various degrees of success have been achieved in by West African countries in the promotion of EIPM. As the science of EIPM continues to evolve and better understanding of the process is gained among policymakers, more studies on effective strategies to improve the evidence-to-policy process are advocated.

Global health systems partnerships: a mixed methods analysis of Mozambique's HPV vaccine delivery network actors

Background

Global health partnerships have expanded exponentially in the last two decades with Gavi, the Vaccine Alliance considered the model’s pioneer and leader because of its vaccination programs’ implementation mechanism. Gavi, relies on diverse domestic and international partners to carry out the programs in low- and middle-income countries under a partnership engagement framework (PEF). In this study, we utilized mixed methods to examine Mozambique’s Gavi driven partnership network which delivered human papillomavirus (HPV) vaccine during the demonstration phase.

Methods

Qualitative tools gauged contextual factors, prerequisites, partner performance and practices while a social network analysis (SNA) survey measured the partnership structure and perceived added value in terms of effectiveness, efficiency and country ownership. Forty key informants who were interviewed included frontline Ministry of Health workers, Ministry of Education staff and supporting partner organization members, of whom 34 participated in the social network analysis survey.

Results

Partnership structure SNA connectivity measurement scores of reachability (100%) and average distance (2.5), were high, revealing a network of very well-connected HPV vaccination implementation collaborators. Such high scores reflect a network structure favorable for rapid and widespread diffusion of information, features necessary for engaging and handling multiple implementation scales. High SNA effectiveness and efficiency measures for structural holes (85%) and low redundancy (30%) coupled with high mean perceived effectiveness (97.6%) and efficiency (79.5%) network outcome scores were observed. Additionally, the tie strength average score of 4.1 on a scale of 5 denoted high professional trust. These are all markers of a collaborative partnership environment in which disparate institutions and organizations leveraged each entity’s comparative advantage. Lower perceived outcome scores for country ownership (24%) were found, with participants citing the prominent role of several out-of-country partner organizations as a major obstacle.

Conclusions

While there is room for improvement on the country ownership aspects of the partnership, the expanded, diverse and inclusive collaboration of institutions and organizations that implemented the Mozambique HPV vaccine demonstration project was effective and efficient. We recommend that the country adapt a similar model during national scale up of HPV vaccination.

Questions for future evidence-informed policy initiatives: insights from the evolution and aspirations of National Immunization Technical Advisory Groups

BACKGROUND

Attention to evidence-informed policy has grown; however, efforts to strengthen the quality and use of evidence are not starting from a blank slate. Changes in health architectures and financing pose different considerations for investments in evidence-informed policy than in the past. We identify major trends that have shifted the environment in which health policies are made, and use the evolution and future aspirations of National Immunization Technical Advisory Groups (NITAGs) in low- and middle-income countries to identify questions the sector must confront when determining how best to structure and strengthen evidence-informed health policy.

DISCUSSION

Trends over the last two decades have resulted in a dense arena with many issue-specific groups, discrete initiatives to strengthen evidence-informed policy and increasing responsibility for subnational institutions. Many countries face a shifting resource base, which for some reduces the amount of resources for health. There is global momentum around universal health coverage, reflecting a broader systems approach, but few examples of how the vast array of stakeholders relate within it are available. NITAG aspirations reflect four interconnected themes related to their scope, their integration in national policy processes, health financing and relationships with ministries of finance, and NITAG positioning relative to other domestic and international entities, raising questions such as, What are the bounds of issue-specific groups and their relationship to allocation decision-making processes across health areas? How do technical advisory groups interface with what are inherently political processes? When are finances considered, by whom and how? What is the future of existing groups whose creation was intended to enhance national ownership but who need continued external support to function? When should new entities be created, in what form and with what mandate?

CONCLUSIONS

Countries must determine who makes decisions about resources, when, using what criteria, and how to do so in a robust yet efficient way given the existing and future landscape. While answers to these questions are necessarily country specific, they are collective matters that cannot be addressed by specialised groups alone and have implications for new investments in evidence-informed policy.

Investigating the process of evidence-informed health policymaking in Bangladesh: a systematic review

Over the last four decades, Bangladesh has made considerable improvements in population health, this is in part due to the use of evidence to inform policymaking. This systematic review aims to better understand critical factors that have facilitated the diffusion of scientific evidence into multiple phases of health policymaking in Bangladesh. To do this an existing policy framework designed by Shiffman and Smith in 2007, was used to extract and synthesize data from selected policy analyses. This framework was used to ensure the content, context and actors involved with evidence-informed policymaking were considered in each case where research had helped shape a health policy. The 'PRISMA Checklist' was employed to design pre-specified eligibility criteria for the selection of information sources, search strategy, inclusion and exclusion criteria, and process of data extraction and synthesis. Through our systematic search conducted from February to May 2017, we initially identified 1859 articles; after removal of duplicates, followed by the screening of titles, abstracts and full-texts, 24 articles were included in the analysis. Health policy issues included the following topics: maternal and child health, tobacco control, reproductive health, infectious disease control and the impact and sustainability of knowledge translation platforms. Findings suggested that research evidence that could be used to meet key targets associated with the Millennium Development Goals (MDGs) were more likely to be considered as a political (and therefore policy) priority. Furthermore, avenues of engagement between research organizations and the government as well as collective action from civil-society organizations were important for the diffusion of evidence into policies. Through this article, it is apparent that the interface between evidence and policy formulation occurs when evidence is, disseminated by a cohesive policy-network with strong leadership and framed to deliver solutions for problems on both the domestic and global development agenda.

Value and effectiveness of National Immunization Technical Advisory Groups in low- and middle-income countries: a qualitative study of global and national perspectives

The Global Vaccine Action Plan proposes that every country establish or have access to a National Immunization Technical Advisory Group (NITAG) by 2020. The NITAG role is to produce evidence-informed recommendations that incorporate local context, to guide national immunization policies and practice. This study aimed to explore the value and effectiveness of NITAGs in low- and middle-income countries (LMICs), identifying areas in which NITAGs may require further support to improve their functionality and potential barriers to global investment. A multi-methods study design was used, comprising 134 semi-structured interviews and 82 literature review sources that included 38 countries. Interviews were conducted with 53 global/regional and 81 country-level participants able to provide insight into NITAG effectiveness, including NITAG members, national immunization programme staff, and global agency representatives (e.g. the World Health Organisation, the Bill and Melinda Gates Foundation, Gavi the Vaccine Alliance). The review, including published and unpublished sources on NITAGs in LMICs, was conducted to supplement and corroborate interview findings. Data were analysed thematically. NITAGs were described as valuable in promoting evidence-informed vaccination decision-making, with NITAG involvement enhancing national immunization programme strength and sustainability. Challenges to NITAG effectiveness included: (1) unreliable funding; (2) insufficient diversity of member expertise; (3) inadequate conflicts of interest management procedures; (4) insufficient capacity to access and use evidence; (5) lack of transparency; and (6) limited integration with national decision-making processes that reduced the recognition and incorporation of NITAG recommendations. LMIC NITAGs have developed significantly in the past decade. Well-functioning NITAGs were trusted national resources that enhanced country ownership of immunization provision. However, many LMIC NITAGs require additional technical and funding support to strengthen quality and effectiveness, while maintaining impartiality and ensuring sufficient integration with national decision-making processes. Barriers to sustainable global support need to be addressed for LMIC NITAGs to both continue and develop further.

The feasibility of universal HPV vaccination program in Shenzhen of China: a health policy analysis

Background

HPV vaccination for the prioritized adolescent girls is well accepted and implemented in developed countries as an effective measure for cervical cancer prevention and control with increasing population-level effectiveness evidence accumulated. This study is to assess the feasibility of universal HPV vaccination among adolescent girls to inform strategies to manage political dimensions of policy-making process in Shenzhen, China, offering insights for other low- and middle-income countries undergoing HPV vaccine introduction.

Methods

Document review and in-depth interviews with identified stakeholders were conducted. The framework of Health Policy Triangle was adapted to guide data collection and analysis in terms of context, actors, process and content. Stakeholder analysis examining actors’ position, power, role and interest and thematic analysis focusing on data coding and theme development were used.

Results

Shenzhen’s contextual factors include legislative authority under a unitary political system, economic developments and cultural values on immunization and sexuality. Stakeholders’ position and power could be explained by their role and interest in the Top-down health administration. Mothers could be potential bystanders if having little knowledge on HPV vaccination. Themes in policy-making process were problem definition, advocacy activities to promote HPV vaccination, HPV vaccine demand and access, the role of media and political attention on evidence-informed policy-making in Shenzhen. These stakeholders also discussed different aspects of program planning prospectively.

Conclusions

Shenzhen witnesses a possibility of demonstration projects for local government’s horizontal accountability but no potential advocates were identified at local level for fragmented organization of public health facilities and health professionals’ lacking mobilization skills. A cervical cancer prevention expert could be a policy entrepreneur. Despite of these challenges, the recommendations to enhance the feasibility include multi-participation to engage non-governmental organizations, pharmaceuticals, target girls and their mothers, power enforcement along governing system, as well as better use of the media.

Antenatal care data sources and their policy and planning implications: a Palestinian example using the Lives Saved Tool

Background

Policy making in healthcare requires reliable and local data. Different sources of coverage data for health interventions can be utilized to populate the Lives Saved Tool (LiST), a commonly used policy-planning tool for women and children’s health. We have evaluated four existing sources of antenatal care data in Palestine to discuss the implications of their use in LiST.

Methods

We identified all intervention coverage and health status indicators around the antenatal period that could be used to populate LiST. These indicators were calculated from 1) routine reported data, 2) a Multiple Indicator Cluster Survey (MICS), 3) paper-based antenatal records and 4) the eRegistry (an electronic health information system) for public clinics in the West Bank, Palestine for the most recent year available. We scaled coverage of each indicator to 90%, in public clinics only, and compared this to a no-change scenario for a seven-year period.

Results

Eight intervention coverage and health status indicators needed to populate the antenatal section of LiST could be calculated from both paper-based antenatal records and the eRegistry. Only two could be calculated from routine reports and three from a national survey. Maternal lives saved over seven years ranged from 5 to 39, with percent reduction in the maternal mortality ratio (MMR) ranging from 1 to 6%. Pre-eclampsia management accounted for 25 to 100% of these lives saved.

Conclusions

The choice of data source for antenatal indicators will affect policy-based decisions when used to populate LiST. Although all data sources have their purpose, clinical data collected directly in an electronic registry during antenatal contacts may provide the most reliable and complete data to populate currently unavailable but needed indicators around specific antenatal care interventions.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6427-8) contains supplementary material, which is available to authorized users.

Vaccine Demand and Willingness-to-pay for Arbovirus Vaccines: A Cross-sectional Survey in Rural Guatemala

BACKGROUND

Arboviruses including dengue (DENV), chikungunya (CHIKV) and Zika cause significant morbidity in Latin America. With multiple arbovirus vaccines in development, better understanding of community attitudes and acceptability for these vaccines is needed.

METHODS

In September 2016, a cross-sectional survey assessed arbovirus knowledge, attitudes, vaccine demand and willingness-to-pay (WTP) at the conclusion of a DENV/norovirus surveillance study in rural Guatemala with high arbovirus endemicity. Factors associated with vaccine demand and WTP were assessed with regression analysis.

RESULTS

Among 564 surveyed households, DENV knowledge was high. There was great concern for arboviruses, particularly CHIKV. Overall vaccine attitudes were positive with <5% identifying significant barriers, hesitancy or refusing previous vaccination. At 50% and 75% efficacy, 75% and 88% of respondents wanted arbovirus vaccines, respectively. DENV vaccine demand at 50% efficacy was associated with increased housing density, nonhealth postvaccination location, older children and medical source for information. For each vaccine, 52-55% of respondents were WTP $0-$3.40, while 16-17% were WTP ≥$6.81. WTP at $3.40 and $6.81 levels for all vaccines was associated positively with parental education but negatively with good DENV knowledge. History of purchasing and identifying barriers to vaccines was associated with WTP ≥$6.81.

CONCLUSIONS

Demand for potential DENV, CHIKV and Zika vaccines is high at 50% and 75% efficacy in this Guatemalan community. Associated factors could be leveraged to optimize arbovirus vaccine implementation. Overall low WTP given current cost of Dengvaxia (Sanofi Pasteur, Lyon, France) suggests that government subsidization may be necessary in resource-poor regions, though a small private market may be supported.

Knowledge translation for public health in low- and middle- income countries: a critical interpretive synthesis

Background

Effective knowledge translation allows the optimisation of access to and utilisation of research knowledge in order to inform and enhance public health policy and practice. In low- and middle- income countries, there are substantial complexities that affect the way in which research can be utilised for public health action. This review attempts to draw out concepts in the literature that contribute to defining some of the complexities and contextual factors that influence knowledge translation for public health in low- and middle- income countries.

Methods

A Critical Interpretive Synthesis was undertaken, a method of analysis which allows a critical review of a wide range of heterogeneous evidence, through incorporating systematic review methods with qualitative enquiry techniques. A search for peer-reviewed articles published between 2000 and 2016 on the topic of knowledge translation for public health in low- and middle – income countries was carried out, and 85 articles were reviewed and analysed using this method.

Results

Four main concepts were identified: 1) tension between ‘global’ and ‘local’ health research, 2) complexities in creating and accessing evidence, 3) contextualising knowledge translation strategies for low- and middle- income countries, and 4) the unique role of non-government organisations in the knowledge translation process.

Conclusion

This method of review has enabled the identification of key concepts that may inform practice or further research in the field of knowledge translation in low- and middle- income countries.

Electronic supplementary material

The online version of this article (10.1186/s41256-018-0084-9) contains supplementary material, which is available to authorized users.

Challenges to sustainable immunization systems in Gavi transitioning countries

The Global Vaccine Action Plan 2011–2020 (GVAP) aims to extend the full benefit of vaccination against vaccine-preventable diseases to all individuals. More than halfway through the Decade of Vaccines, countries classified as Middle-Income by the World Bank struggle to achieve several GVAP targets. Countries transitioning from Gavi, the Vaccine Alliance, represent a key sub-group of Middle Income Countries.

Through a review of available literature on the subject, this study documents the lack of comparative analyses on immunization system performance in countries transitioning from Gavi support. Despite increased emphasis on the importance of programmatic sustainability beyond financing through the Gavi 2016–2020 Strategy and availability of data, existing literature has predominantly documented challenges related to domestic financing of immunization.

This study complements a review of current literature with an analysis of country assessments conducted by immunization partners since 2011, in an effort to document programmatic challenges related to decision-making for immunization policy, delivery of services, and access to affordable and timely supply in Gavi transitioning countries.

In light of the findings, we suggest continued systematic compilation of country performance data beyond financing to inform policy-making, in particular for: (i) development of a more nuanced theory of change towards sustainable immunization programmes and (ii) measurement of progress and key areas for attention and investment.

How Are New Vaccines Prioritized in Low-Income Countries? A Case Study of Human Papilloma Virus Vaccine and Pneumococcal Conjugate Vaccine in Uganda

Background: To date, research on priority-setting for new vaccines has not adequately explored the influence of the global, national and sub-national levels of decision-making or contextual issues such as political pressure and stakeholder influence and power. Using Kapiriri and Martin’s conceptual framework, this paper evaluates priority setting for new vaccines in Uganda at national and sub-national levels, and considers how global priorities can influence country priorities. This study focuses on 2 specific vaccines, the human papilloma virus (HPV) vaccine and the pneumococcal conjugate vaccine (PCV).

Methods: This was a qualitative study that involved reviewing relevant Ugandan policy documents and media reports, as well as 54 key informant interviews at the global level and national and sub-national levels in Uganda. Kapiriri and Martin’s conceptual framework was used to evaluate the prioritization process.

Results: Priority setting for PCV and HPV was conducted by the Ministry of Health (MoH), which is considered to be a legitimate institution. While respondents described the priority setting process for PCV process as transparent, participatory, and guided by explicit relevant criteria and evidence, the prioritization of HPV was thought to have been less transparent and less participatory. Respondents reported that neither process was based on an explicit priority setting framework nor did it involve adequate representation from the districts (program implementers) or publicity. The priority setting process for both PCV and HPV was negatively affected by the larger political and economic context, which contributed to weak institutional capacity as well as power imbalances between development assistance partners and the MoH.

Conclusion: Priority setting in Uganda would be improved by strengthening institutional capacity and leadership and ensuring a transparent and participatory processes in which key stakeholders such as program implementers (the districts) and beneficiaries (the public) are involved. Kapiriri and Martin’s framework has the potential to guide priority setting evaluation efforts, however, evaluation should be built into the priority setting process a priori such that information on priority setting is gathered throughout the implementation cycle.

Vaccine vial monitor availability and use in low- and middle-income countries: A systematic review

INTRODUCTION

The vaccine vial monitor (VVM) registers cumulative heat exposure on vaccines over time. As low- and lower-middle-income countries transition beyond support from the Global Alliance for Vaccines and Immunization (Gavi), they will assume full responsibility for vaccine financing and procurement. It is unclear to what extent countries transitioning out of Gavi support will continue to include VVMs on their vaccines. This paper aims to systematically review evidence on VVM availability and use in low- and middle-income countries to document factors behind global access to and country demand for VVMs. Such results could help identify actions needed to ensure continued use of VVMs in countries that transition out of Gavi support.

METHODS

We performed a systematic review of electronic databases, reference lists, and grey literature in English and French languages with publication dates from 2005 onwards. The studies included were analyzed for the following outcomes: (1) availability and deployment of VVM-labeled vaccines; (2) VVM practices and perceptions in the immunization system; (3) vaccine introduction and decision-making processes; (4) Gavi graduation and vaccine program sustainability.

RESULTS

The study found that VVM availability and use was affected by multiple sourcing of vaccines and the extent to which VVM was included in the vaccine specification in the tendering documents when procuring vaccines. Knowledge about VVM and its impact on the EPI program was found to be high among health workers as well as decision-makers. However, the study also found that weak capacity in key national institutions such as NRA and NPA might impact on demand for VVM. As countries take decisions regarding the adoption of new vaccines, factors such as disease burden and vaccine price may assume greater importance than vaccine characteristics and presentation. Finally, the study found that countries rely largely on the advice and recommendations from technical partners such as WHO and PAHO.

CONCLUSION

The study concludes that global access to and country demand for VVM are dependent on policy statements and recommendations about VVM by key policy institutions such as WHO and UNICEF. The study also concludes that despite Gavi-eligible countries having access to VVM-labeled vaccines, inclusion is often below 100%. Weak institutional capacity in key national agencies such as NRA and NPA seems to be a contributing factor, while other factors include the procurement of clear national policies on the inclusion of VVM on vaccines, along with the capacity to enforce the policy. Finally, the study concludes that knowledge about VVM and its impact on vaccine program efficiency, safety, and cost is critical for transitioning countries' continuous demand for VVM.

Knowledge and power in policy-making for child survival in Niger

Calls to enhance the use of scientific evidence in international health and development policy have increased in recent years; however, analytic frameworks for understanding evidence use focus narrowly on scientific research and were created using data and observations nearly exclusively from Western countries. We examine processes of health policy development in a case study of Niger, a low-income West African country that adopted integrated community case management of childhood illness (iCCM) beginning in 2007, resulting in measurable declines in child mortality. Data collection included in-depth interviews with policy actors in Niger (N = 32), document review (N = 103) and direct observation of policy forums (N = 3). Data analysis used process tracing methodology and applied an Aristotelian definition of "knowledge" as 1) episteme (facts), 2) techne (skills) and 3) phronesis (practical wisdom), while also using a critical perspective to understand issues of power. We found sharp differentials in policy-makers' possession and use of codified forms of knowledge (episteme), with Nigerien policy officers' access highly mediated by actors at international agencies. Government policy-makers possessed skills and capacities (techne) to negotiate with donors and deliberate and weigh conflicting considerations; however they lacked capacity and resources to formally evaluate and document programs and thus reliably draw lessons from them. Practical wisdom (phronesis) emerged as key to the iCCM policy enterprise, particularly among Nigerien government actors, who used logical and ethical arguments to make decisions later found to be critical to iCCM's success. While codified knowledge confers power on members of policy discussions who can access it, this represents only one form of knowledge used in the policy process and perhaps not the most important. Future research on evidence-based policy should use broader definitions of evidence or knowledge, examine on how power conditions the use of knowledge, and examine challenges specific to low-resource policy environments.

Identification and Prioritization of the Economic Impacts of Vaccines

Understanding the most important economic impacts of vaccines can provide relevant information to stakeholders when selecting vaccine immunization strategies from a broader perspective. This study was therefore designed to first identify economic impacts to vaccinated individuals and, second, assess the relative importance of these economic impacts. A four-step approach was used, including a review of the literature, a pilot study, and expert consultation. As a fourth step, a survey utilizing a best-worst scaling was conducted among 26 different stakeholders to assess the relative importance of the identified economic impacts. In each of the 15 choice tasks, participants were asked to choose the most important and the least important economic impact from a set of four from the master list. We identified 23 economic impacts relevant for vaccine introduction. Four domains were identified, namely, health related benefits to vaccinated individuals, short- and long-term productivity gains, community or health systems externalities, and broader economic indicators. The first domain was seen as especially important with mortality, health care expenditure, and morbidity ranking in the top three overall. In conclusion, our study suggests that domain A “health related benefits to vaccinated individuals” are valued as more important than the other economic impacts.

Costs of introducing pneumococcal, rotavirus and a second dose of measles vaccine into the Zambian immunisation programme: Are expansions sustainable?

Background

Introduction of new vaccines in low- and lower middle-income countries has accelerated since Gavi, the Vaccine Alliance was established in 2000. This study sought to (i) estimate the costs of introducing pneumococcal conjugate vaccine, rotavirus vaccine and a second dose of measles vaccine in Zambia; and (ii) assess affordability of the new vaccines in relation to Gavi’s co-financing and eligibility policies.

Methods

Data on ‘one-time’ costs of cold storage expansions, training and social mobilisation were collected from the government and development partners. A detailed economic cost study of routine immunisation based on a representative sample of 51 health facilities provided information on labour and vaccine transport costs. Gavi co-financing payments and immunisation programme costs were projected until 2022 when Zambia is expected to transition from Gavi support. The ability of Zambia to self-finance both new and traditional vaccines was assessed by comparing these with projected government health expenditures.

Results

‘One-time’ costs of introducing the three vaccines amounted to US$ 0.28 per capita. The new vaccines increased annual immunisation programme costs by 38%, resulting in economic cost per fully immunised child of US$ 102. Co-financing payments on average increased by 10% during 2008–2017, but must increase 49% annually between 2017 and 2022. In 2014, the government spent approximately 6% of its health expenditures on immunisation. Assuming no real budget increases, immunisation would account for around 10% in 2022. Vaccines represented 1% of government, non-personnel expenditures for health in 2014, and would be 6% in 2022, assuming no real budget increases.

Conclusion

While the introduction of new vaccines is justified by expected positive health impacts, long-term affordability will be challenging in light of the current economic climate in Zambia. The government needs to both allocate more resources to the health sector and seek efficiency gains within service provision.

Introduction of pentavalent vaccine in Indonesia: a policy analysis

The introduction of pentavalent vaccine containing Haemophilus influenzae type b antigen in Indonesia's National Immunization Program occurred nearly three decades after the vaccine was first available in the United States and 16 years after Indonesia added hepatitis B vaccine into the program. In this study, we analyzed the process that led to the decision to introduce pentavalent vaccine in Indonesia. Using process tracing and case comparison, we used qualitative data gathered through interviews with key informants and data extracted from written sources to identify four distinct but interrelated processes that were involved in the decision making: (a) pentavalent vaccine use policy process, (b) financing process, (c) domestic vaccine development process and (d) political process. We hypothesized that each process is associated with four necessary conditions that are jointly sufficient for the successful introduction of pentavalent vaccine in Indonesia, namely (a) an evidence-based vaccine use recommendation, (b) sufficient domestic financing capacity, (c) sufficient domestic vaccine manufacturing capacity and (d) political support for introduction. This analysis of four processes that led to the decision to introduce a new vaccine in Indonesia may help policy makers and other stakeholders understand and manage activities that can accelerate vaccine introduction in the future.

Ambiguous Capture: Collaborative Capitalism and the Meningitis Vaccine Project

The primary health care approach advanced at Alma Ata to address social determinants of health was replaced by selective health care a year later at Bellagio. Subsequently, immunization was endorsed as a cost-effective technical intervention to combat targeted infectious diseases. Multilateral efforts to collaborate on immunization as a universal public health good ambiguously capture the interests of the world’s governments as well as private, public, and not-for-profit institutions. Global assemblages of scientists, governments, industry and nongovernmental organizations now work in public-private partnerships to develop and make essential vaccines accessible, with vaccines marketed as single fix solutions for global health. Drawing from ethnographic fieldwork in France and Burkina Faso that followed the development, regulation, and implementation of the group A meningococcal conjugate vaccine for sub-Saharan Africa, in this article I describe events during and after the development of MenAfriVac. A technological success narrative steeped in collaborative capitalist rhetoric disguises neglected health care systems.

Quantifying the broader economic consequences of quadrivalent human papillomavirus (HPV) vaccination in Germany applying a government perspective framework

HPV infections can cause substantial burden in females and males as it is associated with several genital cancers, in addition to genital warts. Traditional economic evaluations often focus on quantifying cost-effectiveness, however, it is increasingly recognized that vaccinations may generate broader benefits not captured in cost-effectiveness analysis. Τhe aim of this study was to evaluate the broader economic consequences associated with HPV vaccination in males and females and to conduct a lifetime cost-benefit analysis of investing in universal vaccination in Germany from the perspective of government. Methodologies from generational accounting, human capital and health economics were combined to estimate the broader economic consequences of HPV vaccination including the fiscal impact for the government. A cohort model was developed simulating the medical costs and average lifetime fiscal transfers between the government and 12-year-old immunized and non-immunized males and females. To estimate tax revenue attributed to vaccination-related changes in morbidity and mortality, direct and indirect tax rates were linked to differences in age- and gender-specific earnings. Based on HPV vaccination costs, the base case cost-benefit analysis demonstrated that investing <euro>1 in universal HPV vaccination could yield <euro>1.7 in gross tax revenue over the lifetime of the cohorts. After taking into consideration the governmental transfers, universal HPV vaccination in Germany could result in incremental positive net discounted taxes (i.e. tax revenue-transfers) from <euro>62 million for the German government. The vaccination of males and females with the quadrivalent HPV vaccine is likely to have positive effects on public finances.

Assessment of parental perception of malaria vaccine in Tanzania

Background

Clinical trials of the RTS,S malaria vaccine have completed Phase III and the vaccine is on track for registration. Before making decisions about implementation, it is essential to prepare the ground for introducing the vaccine by assessing awareness and willingness to use malaria vaccines and to provide policy makers with evidence-based information on the best strategies to engage communities to manage the introduction of malaria vaccine in Tanzania.

Methods

In November 2011, as part of a large cross-sectional study of all 23 regions of Tanzania (mainland Tanzania and Zanzibar) was conducted during Tanzanian Integrated Measles Campaign (IMC) survey. In this study, the variables of interests were awareness and willingness to use a malaria vaccine. The main outcome measure was willingness to use a malaria vaccine. Logistic regression was used to examine the influence of predictive factors.

Results

A representative sample of 5502 (out of 6210) women, aged 18 years or older and with children under 11 months old, was selected to participate, using random sampling probability. Awareness of the forthcoming malaria vaccine, 11.8 % of participants in mainland Tanzania responded affirmatively, compared to 3.4 % in Zanzibar (p value <0.0001). 94.5 % of all respondents were willing to vaccinate their children against malaria, with a slight difference between mainland Tanzania (94.3 %) and Zanzibar (96.8 %) (p value = 0.0167).

Conclusions

Although mothers had low awareness and high willingness to use malaria vaccine, still availability of malaria vaccine RTS,S will compliment other existing malaria interventions and it will be implemented through the Immunization, Vaccines and Biologicals (IVB) programme (formerly EPI). The information generated from this study can aid policy makers in planning and setting priorities for introducing and implementing the malaria vaccine.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-0889-7) contains supplementary material, which is available to authorized users.

Stakeholders' perception on including broader economic impact of vaccines in economic evaluations in low and middle income countries: a mixed methods study

Background

Current health economic evaluation guidelines mainly concentrate on immediate health gains and cost savings for the individual involved in the intervention. However, it has been argued that these guidelines are too narrow to capture the full impact of vaccination in low and middle income countries. The inclusion of broader economic impact of vaccines (BEIV) has therefore been proposed. Some examples of these are productivity-related gains, macro-economic impact, and different externalities. Despite their potency, the extent to which such benefits can and should be incorporated into economic evaluations of vaccination is still unclear. This mixed methods study aims to assess the relevance of BEIV to different stakeholders involved in the vaccine introduction decision making process.

Methods

In this mixed method study an internet based survey was sent to attendees of the New and Underutilized Vaccines Initiative meeting in Montreux, Switzerland in 2011. Additionally, semi-structured interviews of 15 minutes each were conducted during the meeting. Study participants included decision makers, experts and funders of vaccines and immunization programs in low and middle income countries. Descriptive analysis of the survey, along with identification of common themes and factors extracted from the interviews and open survey questions was undertaken.

Results

Evidence on macro-economic impact, burden of disease and ecological effects were perceived as being most valuable towards aiding decision making for vaccine introduction by the 26 survey respondents. The 14 interviewees highlighted the importance of burden of disease and different types of indirect effects. Furthermore, some new interpretations of BEIVs were discussed, such as the potential negative impact of wastage during immunization programs and the idea of using vaccines as a platform for delivering other types of health interventions. Interviewees also highlighted the importance of using a broader perspective in connection to measuring economic impacts, particularly when attempting to derive the value of newer, more expensive vaccines.

Conclusion

According to participants, BEIVs were seen as being equally important as traditional outcome measures used in cost-effectiveness analyses. Such insight can be used to shape research agendas within this field and to eventually create broader, more inclusive practical guidelines for economic evaluations of vaccines.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1638-0) contains supplementary material, which is available to authorized users.

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

Health economics is a relatively new discipline, though its antecedents can be traced back to William Petty FRS (1623-1687). In high-income countries, the academic discipline and scientific literature have grown rapidly since the 1960s. In low- and middle-income countries, the growth of health economics has been strongly influenced by trends in health policy, especially among the international and bilateral agencies involved in supporting health sector development. Valuable and influential research has been done in areas such as cost-benefit and cost-effectiveness analysis, financing of healthcare, healthcare provision, and health systems analysis, but there has been insufficient questioning of the relevance of theories and policy recommendations in the rich world literature to the circumstances of poorer countries. Characteristics such as a country's economic structure, strength of political and social institutions, management capacity, and dependence on external agencies, mean that theories and models cannot necessarily be transferred between settings. Recent innovations in the health economics literature on low- and middle-income countries indicate how health economics can be shaped to provide more relevant advice for policy. For this to be taken further, it is critical that such countries develop stronger capacity for health economics within their universities and research institutes, with greater local commitment of funding.

National health policy-makers' views on the clarity and utility of Countdown to 2015 country profiles and reports: findings from two exploratory qualitative studies

BACKGROUND

The use of sets of indicators to assess progress has become commonplace in the global health arena. Exploratory research has suggested that indicators used for global monitoring purposes can play a role in national policy-making, however, the mechanisms through which this occurs are poorly understood. This article reports findings from two qualitative studies that aimed to explore national policy-makers' interpretation and use of indicators from country profiles and reports developed by Countdown to 2015.

METHODS

An initial study aimed at exploring comprehension of Countdown data was conducted at the 2010 joint Women Deliver/Countdown conference. A second study was conducted at the 64th World Health Assembly in 2011, specifically targeting national policy-makers. Semi-structured interviews were carried out with 29 and 22 participants, respectively, at each event. Participants were asked about their understanding of specific graphs and indicators used or proposed for use in Countdown country profiles, and their perception of how such data can inform national policy-making. Responses were categorised using a framework analysis.

RESULTS

Respondents in both studies acknowledged the importance of the profiles for tracking progress on key health indicators in and across countries, noting that they could be used to highlight changes in coverage, possible directions for future policy, for lobbying finance ministers to increase resources for health, and to stimulate competition between neighbouring or socioeconomically similar countries. However, some respondents raised questions about discrepancies between global estimates and data produced by national governments, and some struggled to understand the profile graphs shown in the absence of explanatory text. Some respondents reported that use of Countdown data in national policy-making was constrained by limited awareness of the initiative, insufficient detail in the country profiles to inform policy, and the absence of indicators felt to be more appropriate to their own country contexts.

CONCLUSIONS

The two studies emphasise the need for country consultations to ensure that national policy-makers understand how to interpret and use tools like the Countdown profile for planning purposes. They make clear the value of qualitative research for refining tools used to promote accountability, and the need for country level Countdown-like processes.

The use of supplementary immunisation activities to improve uptake of current and future vaccines in low-income and middle-income countries: a systematic review protocol

INTRODUCTION

Immunisation coverage data in low-income and middle-income countries (LMICs) suggest that more strategies need to be implemented to achieve and sustain optimal vaccine uptake. Among possible strategies to improve immunisation coverage are supplementary immunisation activities (SIAs). We are therefore interested in conducting a systematic review to assess whether SIAs complement routine immunisation programmes to improve vaccination coverage and prevent disease outbreaks.

METHODS

Our systematic review will focus on studies conducted in LMICs. With the help of an information specialist, we will search for eligible studies in PubMed, Web of Science, Scopus, Africa-Wide, Cochrane Library, WHOLIS, CINAHL, PDQ-Evidence as well as reference lists of relevant publications. Additionally, we will contact relevant organisations such as WHO and GAVI. Two authors will independently extract data from eligible studies and independently assess risk of bias by assessing the adequacy of study characteristics. The primary meta-analysis will use random effects models due to expected interstudies heterogeneity. Dichotomous data will be analysed using relative risk and continuous data using weighted mean differences (or standardised mean differences), both with 95% CIs.

DISCUSSION

The findings from this systematic review will be discussed in the context of strengthening routine childhood immunisation services, routine adolescent immunisation services and introduction of future vaccines against tuberculosis and HIV/AIDS.

STUDY STRENGTHS

Unbiased selection of many studies conducted in different settings. This will strengthen the validity of the review results.

STUDY LIMITATIONS

Heterogeneity of the study settings of the low-income, lower-middle-income and upper-middle-income countries as well as heterogeneity in study designs.

Political and institutional influences on the use of evidence in public health policy. A systematic review

Background

There is increasing recognition that the development of evidence-informed health policy is not only a technical problem of knowledge exchange or translation, but also a political challenge. Yet, while political scientists have long considered the nature of political systems, the role of institutional structures, and the political contestation of policy issues as central to understanding policy decisions, these issues remain largely unexplored by scholars of evidence-informed policy making.

Methods

We conducted a systematic review of empirical studies that examined the influence of key features of political systems and institutional mechanisms on evidence use, and contextual factors that may contribute to the politicisation of health evidence. Eligible studies were identified through searches of seven health and social sciences databases, websites of relevant organisations, the British Library database, and manual searches of academic journals. Relevant findings were extracted using a uniform data extraction tool and synthesised by narrative review.

Findings

56 studies were selected for inclusion. Relevant political and institutional aspects affecting the use of health evidence included the level of state centralisation and democratisation, the influence of external donors and organisations, the organisation and function of bureaucracies, and the framing of evidence in relation to social norms and values. However, our understanding of such influences remains piecemeal given the limited number of empirical analyses on this subject, the paucity of comparative works, and the limited consideration of political and institutional theory in these studies.

Conclusions

This review highlights the need for a more explicit engagement with the political and institutional factors affecting the use of health evidence in decision-making. A more nuanced understanding of evidence use in health policy making requires both additional empirical studies of evidence use, and an engagement with theories and approaches beyond the current remit of public health or knowledge utilisation studies.